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 |
2204 |
2024-05-06 18:56 |
Anonymous (not verified) |
94.188.205.168 |
Jim saukko |
Proprietorship |
13232 nw 30 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. |
2024-05-05 |
Jim Saukko |
saukkogt500@gmail.com |
Polk city |
IA |
United States |
Dawn brown |
Kirk moser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jim Saukko |
saukkogt500@gmail.com |
Self |
Polk city |
IA |
IA |
Dawn brown |
Kirk moser |
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 |
2152 |
2024-04-15 17:23 |
Anonymous (not verified) |
94.188.207.230 |
ServiceMaster by Harris |
Proprietorship |
432 Locust 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. |
2024-04-15 |
Joel Harris |
joel.harris@forbin.net |
Waterloo |
IA |
IA |
None |
None |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Harris |
joel.harris@forbin.net |
Owner |
Waterloo |
IA |
IA |
None |
None |
Signed |
1001 |
2022-03-23 10:37 |
Anonymous (not verified) |
104.201.100.158 |
Joel Jacobsen |
Proprietorship |
1337 S 7th 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 |
Joel Jacobsen |
jjacobsen@phillipsstafford.com |
Adel |
Iowa |
United States |
Luke Peterson |
Luke van Roekel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Jacobsen |
jjacobsen@phillipsstafford.com |
Self |
Adel |
Iowa |
United States |
Luke Peterson |
Luke Van Roekel |
Signed |
1104 |
2022-05-16 13:00 |
Anonymous (not verified) |
65.144.174.26 |
Medrano Flooring LLC |
Limited Liability Company |
8186 Harbach Blvd Apt 1, 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. |
2022-05-16 |
Joel Medrano |
medranojoel397@gmail.com |
Clive |
Polk |
Iowa |
Ana Leon |
Jesus Maldonado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Medrano |
medranojoel397@gmail.com |
Self |
Clive |
Polk |
Iowa |
Ana Leon |
Jesus Maldonado |
Signed |
995 |
2022-03-22 14:40 |
Anonymous (not verified) |
50.82.130.211 |
Pietig Construction, LLC |
Limited Liability Company |
302 Brookside Dr, 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. |
2022-03-09 |
Joel Pietig |
cmins_re@mchsi.com |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Pietig |
cmins_re@mchsi.com |
Owner/Self |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
1655 |
2023-05-19 14:19 |
Anonymous (not verified) |
94.188.207.229 |
Cutting Edge Concrete LLC |
Limited Liability Company |
325 Linn 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. |
2023-05-19 |
Joel Waltz |
joel@cuttingedgeiowa.com |
Boone |
Boone |
Iowa |
Robert Simmons |
Deb Ernst |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Waltz |
joel@cuttingedgeiowa.com |
Self |
Boone |
Boone |
IA |
Robert Simmons |
Deb Ernst |
Signed |
1837 |
2023-09-11 19:10 |
Anonymous (not verified) |
94.188.207.230 |
TBA Handyman service |
Limited Liability Company |
619 e 10th st. north 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. |
2023-09-11 |
Joey Conkling |
tba050402@gmail.com |
newton |
jasper |
Iowa |
Ashton tyler conkling |
Bianca Storm Conkling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TBA Handyman Service |
tbaconstruction02@gmail.com |
self |
newton |
jasper |
iowa |
Ashton tyler Conkling |
Bianca Storm Conkling |
Signed |
2036 |
2024-02-07 16:22 |
Anonymous (not verified) |
94.188.207.226 |
JR CONSTRUCTION |
Proprietorship |
502 JOHNSON STREET, 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. |
2024-02-07 |
JOHAN PETERS REIMER |
reimerjohan16@gmail.com |
ALTA |
BUENA VISTA |
IOWA |
NEIL THIESSEN MARTENS |
PETER KLASSEN MARTENS |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOHAN PETERS REIMER |
reimerjohan16@gmail.com |
SELF |
ALTA |
BUENA VISTA |
IOWA |
NEIL THIESSEN MARTENS |
PETER KLASSEN MARTENS |
Signed |
2002 |
2024-01-26 17:00 |
Anonymous (not verified) |
94.188.207.228 |
Legacy Group Consulting |
Limited Liability Company |
3721 Coppermill 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. |
2024-01-26 |
John A Scott |
legacygrpconsulting@gmail.com |
Cedar Rapids |
Linn |
IA |
Barbara Scott |
Robert Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John A Scott |
legacygrpconsulting@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Barbara Scott |
Robert Moore |
Signed |
1112 |
2022-05-17 14:15 |
Anonymous (not verified) |
24.162.40.106 |
Davis AG Service Texas LLC |
Limited Liability Company |
P.O. Box 1475 Fabens, Texas 79838 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Owner |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
1113 |
2022-05-17 14:20 |
Anonymous (not verified) |
24.162.40.106 |
John Anthony Davis |
Proprietorship |
P.O. Box 2551 Mountain View, AR 72560 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Proprietor |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
1615 |
2023-04-27 17:42 |
Anonymous (not verified) |
94.188.207.227 |
John Anthony Davis |
Proprietorship |
P.O. Box 2551 Mountain View, AR 72560 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Proprietor |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
1616 |
2023-04-27 17:46 |
Anonymous (not verified) |
94.188.207.230 |
Davis AG Service Texas LLC |
Limited Liability Company |
P.O. Box 1475 Fabens, Texas 79838 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Owner |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
2028 |
2024-02-07 09:41 |
Anonymous (not verified) |
94.188.207.228 |
J & J SIDING |
Proprietorship |
214 6TH STREET, P.O. BOX 482, LAKE VIEW, IOWA 51450 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
JOHN CLARENCE OLERICH |
bigo@netins.net |
LAKE VIEW |
SAC |
IOWA |
ROBERT EUGENE BELT |
NEIL THIESSEN MARTENS |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOHN CLARENCE OLERICH |
bigo@netins.net |
SELF |
LAKE VIEW |
SAC |
IOWA |
ROBERT EUGENE BELT |
NEIL THIESSEN MARTENS |
Signed |
1829 |
2023-09-06 16:21 |
Anonymous (not verified) |
94.188.207.228 |
JC Electric, LLC |
Limited Liability Company |
205 South Clinton St., Apt 4, 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. |
2023-09-05 |
John Coady |
jcelectric.john@gmail.com |
Albia |
IA |
United States |
Todd Ryan |
Jer McAnich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Coady |
jcelectric.john@gmail.com |
Self |
Albia |
Monroe |
IA |
Todd Ryan |
Jer McAnich |
Signed |
2175 |
2024-04-24 09:14 |
Anonymous (not verified) |
94.188.207.229 |
John Sapp |
Proprietorship |
2120 South Main Street Burlington, IA52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
John Curtis Sapp Jr. |
jbuddysapp@gmail.com |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John C. Sapp Jr. |
jbuddysapp@gmail.com |
owner |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2186 |
2024-04-28 11:12 |
Anonymous (not verified) |
94.188.205.168 |
John Martin |
Proprietorship |
1378 60th avenue Blue Grass 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. |
2024-04-28 |
John D Martin |
martinflooring@netzero.com |
Blue Grass |
Muscatine |
Iowa |
John D Martin |
John D Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John D Martin |
martinflooring@netzero.com |
Owner |
Blue Grass |
Muscatine |
Iowa |
John D Martin |
John D Martin |
Signed |
140 |
2020-04-28 10:13 |
Anonymous (not verified) |
74.84.101.138 |
Lutheran Cemetery Association |
Proprietorship |
410 S. Mechanic 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. |
2020-02-21 |
John D Noel |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John D Noel |
chelsea.whalen@upperiowains.com |
President |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
2173 |
2024-04-23 14:19 |
Anonymous (not verified) |
94.188.205.166 |
Duer and Sons Remodeling, Inc |
Partnership |
1795 Se 82nd St, Runnells Iowa 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. |
2024-04-23 |
John Duer |
John@duerandsonsremodeling.com |
Runnells |
Polk |
Iowa |
Travis Justice |
Jake VanGorp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Duer |
John@duerandsonsremodeling.com |
Owner |
Runnells |
Polk |
Iowa |
Travis Justice |
Jake VanGorp |
Signed |
859 |
2022-01-27 11:29 |
Anonymous (not verified) |
204.155.61.217 |
JD Drywall |
Proprietorship |
503 9th Street Kalona, Iowa 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. |
2022-01-27 |
John Duwa |
johnduwa@outlook.com |
Kalona |
Washington |
Iowa |
Angela Stutzman |
Jeff Spenner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JD Drywall - John Duwa |
johnduwa@outlook.com |
owner |
Kalona |
Washington |
Iowa |
Angela Stutzman |
Jeff Spenner |
Signed |
892 |
2022-02-03 15:52 |
Anonymous (not verified) |
204.155.61.217 |
JD DRYWALL |
Proprietorship |
503 9th Street Kalona, Iowa 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. |
2022-02-03 |
John Duwa |
johnduwa@outlook.com |
Kalona |
Washington |
Iowa |
Jeff Spenner |
Angela Stutzman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JD Drywall - John Duwa |
johnduwa@outlook.com |
owner |
Kalona |
Washington |
Iowa |
Jeff Spenner |
Angela Stutzman |
Signed |
1855 |
2023-09-27 12:56 |
Anonymous (not verified) |
94.188.207.224 |
Lincoln Hotel Group |
Limited Liability Company |
9240 Andermatt Drive Suite 1 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-27 |
John Edward Klimpel |
jklimpel@lincolnhotelgroup.com |
Lincoln |
Lancaster |
NE |
Carrie A. Fleck |
Jill N. Korta |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brent Besch |
brent.besch@marshmma.com |
Client |
Lincoln |
Nebraska |
NE |
Carrie A Fleck |
Jill N Korta |
Signed |
808 |
2021-12-20 12:28 |
Anonymous (not verified) |
107.77.209.143 |
Painting & Design |
Proprietorship |
2728 51st 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. |
2021-12-20 |
John Eugene Herman |
jherman30@yahoo.com |
Des moines |
Polk |
Iowa |
Peggy Noplos |
Jennifer Herman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Herman |
jherman30@yahoo.com |
Self |
Des moines |
Polk |
Iowa |
Peggy Noplos |
Jennifer Herman |
Signed |
987 |
2022-03-20 10:53 |
Anonymous (not verified) |
75.162.173.186 |
John Greenman Painting |
Proprietorship |
111 Village Drive 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. |
2022-03-20 |
john greenman |
greenmanj55@gmail.com |
west des moines |
iowa |
iowa |
Angela Kay Olsem |
Peggy Ann Greenman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John William Greenman |
greenmanj55@gmail.com |
owner |
west des moines |
iowa |
iowa |
Angela Kay Olsem |
Peggy Ann Greenman |
Signed |
1083 |
2022-05-02 13:42 |
Anonymous (not verified) |
173.18.233.175 |
John Helm |
Proprietorship |
417 Pleasant Hill DR Atkins, IA 52206 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
John Helm |
johnhelmconstruction22@gmail.com |
Atkins |
Benton |
Iowa |
Brian Ashlock |
Trevor Vick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Helm |
johnhelmconstruction22@gmail.com |
Owner |
Atkins |
Benton |
IOWA |
Brian Ashlock |
Trevor Vick |
Signed |
796 |
2021-12-15 07:58 |
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 |
John Kenneth Lampe |
lampeappliance@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Douglas James 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 |
IA |
Linn |
Douglas James Lampe |
Kenneth Roman Lampe |
Signed |
2001 |
2024-01-26 10:41 |
Anonymous (not verified) |
94.188.207.225 |
4 Sons Splicing & Activation |
Proprietorship |
13510 W Brazos Bend Dr, Needville, TX 77461-9525 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-26 |
John Kevin Steil |
foursons1990@steil.org |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Helen Frances Steil |
foursons1990@steil.org |
Spouse |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
1088 |
2022-05-04 16:00 |
Anonymous (not verified) |
50.80.16.238 |
American Gutter Company LLC |
Proprietorship |
2015 Andrew Charles Dr 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. |
2022-05-04 |
John Kuper |
american.guttercompanyllc@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Kirstin Hagerty |
Vic Kuper |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Kuper |
american.guttercompanyllc@gmail.com |
Owner |
CEDAR RAPIDS |
Linn |
IA |
Kirstin Hagerty |
Vic Kuper |
Signed |
292 |
2020-10-27 18:15 |
Anonymous (not verified) |
173.19.162.248 |
John Lass |
Limited Liability Company |
6025 SE 16TH 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. |
2020-10-27 |
John Lass |
johnwlass@gmail.com |
Des Moines |
IA |
United States |
Dawn Lass |
Gordon Lamp Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Lass |
johnwlass@gmail.com |
self |
Des Moines |
IA |
United States |
Dawn Lass |
Gordon Lamp Jr |
Signed |
1024 |
2022-04-01 09:25 |
Anonymous (not verified) |
173.23.251.188 |
Norwalk Exterior Home Improvement |
Proprietorship |
6391 Grimes St 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. |
2022-04-01 |
John Lester |
norwalkexterior@gmail.com |
Indianola |
Warren |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Lester |
norwalkexterior@gmail.com |
owner |
Indianola |
Warren |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
1180 |
2022-07-06 03:55 |
Anonymous (not verified) |
172.58.83.226 |
John lewis |
Limited Liability Company |
2130 lay 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. |
2022-07-06 |
John lewis |
johnericklewis@gmail.com |
Des Moines |
polk |
iowa |
Robert Rodriguez |
Penny scroggins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay skills transport |
johnericklewis@gmail.com |
friend |
Des Moines |
polk |
iowa |
John lewis |
panny scrogging |
Signed |
1503 |
2023-03-07 12:45 |
Anonymous (not verified) |
94.188.205.177 |
Al's Roofing LLC |
Limited Liability Company |
P O Box 277 Lime Springs, 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. |
2022-04-18 |
John Martin |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Al's Roofing LLC |
darrele@ciains.biz |
agent |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
565 |
2021-07-08 13:42 |
Anonymous (not verified) |
173.25.132.255 |
Communications Construction Services LLC |
Limited Liability Company |
1315 East 38th 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. |
2021-07-08 |
John McCann Jr |
communicationconstructionllc@gmail.com |
Des Moines |
IA |
United States |
Laura McCann |
David Garza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura McCann |
communicationconstructionllc@gmail.com |
spouse |
Des Moines |
IA |
United States |
John J McCann Jr |
David Christopher Garza III |
Signed |
527 |
2021-05-20 07:54 |
Anonymous (not verified) |
66.43.242.142 |
mcconnells custom construction |
Proprietorship |
1074 240th 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 |
John McConnell |
jnkatmcc@netins.net |
jefferson |
greene |
ia |
Jordan Hostetler |
Mark Aspengren |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
McConnell's Custom Construction |
jnkatmcc@netins.net |
owner |
jefferson |
greene |
ia |
Jordan Hostetler |
Mark Aspengren |
Signed |
392 |
2021-02-11 10:07 |
Anonymous (not verified) |
192.30.185.142 |
Neiman Electric |
Proprietorship |
301 West Creek Dr, Lawton, IA 51030 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-11 |
John Neiman, Jr |
neiman009@yahoo.com |
Lawton |
Woodbury |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Neiman, Jr. |
neiman009@yahoo.com |
Owner |
Lawton |
Woodbury |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
219 |
2020-07-31 08:49 |
Anonymous (not verified) |
173.31.147.225 |
JOHN RUPP |
Proprietorship |
3110 TYLER AVENUE 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. |
2020-07-30 |
JOHN P RUPP |
THEELECTRICIANLLC@OUTLOOK.COM |
HARTLEY |
OBRIEN |
IOWA |
TAMI KLEIN |
KRIS WALKER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOHN P RUPP |
THEELECTRICIANLLC@OUTLOOK.COM |
SELF |
HARTLEY |
OBRIEN |
IA |
TAMI KLEIN |
KRIS WALKER |
Signed |
1320 |
2022-09-22 18:01 |
Anonymous (not verified) |
50.33.24.168 |
John Miller Trucking |
Proprietorship |
2414 180th Avenue Porter MN 56280 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
John Patrick Miller |
jkmiller@frontiernet.net |
Porter |
Yellow Medicine |
Minnesota |
Lois Verhelst |
Tricia Bueltel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Patrick Miller |
jkmiller@frontiernet.net |
Self |
Porter |
Yellow Medicine |
Minnesota |
Lois Verhelst |
Tricia Bueltel |
Signed |
1079 |
2022-04-28 16:18 |
Anonymous (not verified) |
3.217.29.203 |
John Paul Pokorny |
Proprietorship |
500 W Adams St., Creston, 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. |
2022-02-04 |
John Paul Pokorny |
tylerins@tyleriowa.com |
Creston |
Union |
Iowa |
Jacquie Merritt |
Wendi Eslinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Paul Pokorny |
tylerins@tyleriowa.com |
Owner |
Creston |
Union |
Iowa |
Jacquie Merritt |
Wendi Eslinger |
Signed |
491 |
2021-04-20 15:57 |
Anonymous (not verified) |
199.102.210.217 |
mjm,inc |
Proprietorship |
32345 200th st dallas centert 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. |
2021-04-20 |
john paul wewrner |
johnpwerner17@gmail.com |
osage |
michell |
ia |
carolyn lee werner |
amanda lee johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
johnwerner |
johnpwerner17@gmail.com |
friend |
osage |
mithell |
ia |
carolyn lee werner |
amanda lee johnson |
Signed |
14 |
2019-12-30 17:22 |
Anonymous (not verified) |
173.20.51.69 |
Rotten Love LLC |
Limited Liability Company |
1101 Valentine Drive, Dubuque Iowa 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-01-01 |
john rettenmeier |
jrettenmeier@gmail.com |
dubuque |
Dubuque |
iowa |
Carolyn Schmid |
Joe Rettenmeier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carolyn Schmid |
jrettenmeier@gmail.com |
owner |
Dubuque |
Dubuque |
iowa |
John Rettenmeier |
John Rettenmeier |
Signed |
526 |
2021-05-19 09:36 |
Anonymous (not verified) |
66.188.136.150 |
John Robinson |
Proprietorship |
12990 E 48th Ave. Denver, CO 80239 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-18 |
John Robinson |
kschumacher@tricorinsurance.com |
Denver |
Denver |
CO |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Robinson |
kschumacher@tricorinsurance.com |
Same |
Denver |
Denver |
CO |
Mitch Kemp |
Shuree Behr |
Signed |
428 |
2021-03-10 12:38 |
Anonymous (not verified) |
66.188.136.150 |
John Smith |
Proprietorship |
2490 E Main St. Lot 41, Plainfield, IN 46168 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
John Smith |
kschumacher@tricorinsurance.com |
Plainfield |
Hendricks |
IN |
Russell Masartis |
Amanda Seeberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Smith |
kschumacher@tricorinsurance.com |
Same |
Plainfield |
Hendricks |
IN |
Russell Masartis |
Amanda Seeberger |
Signed |
1053 |
2022-04-14 21:08 |
Anonymous (not verified) |
50.83.192.136 |
John E Snyder JR |
Proprietorship |
1677 PACIFIC ST, MURRAY, IA 50174 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
John Snyder JR |
jrsweldingia@gmail.com |
MURRAY |
Clarke |
Iowa |
Shelly Goslar |
Dorene Short |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Snyder JR |
jrsweldingia@gmail.com |
Selg |
MURRAY |
Clarke |
Iowa |
Shelly Goslar |
Dorene Short |
Signed |
538 |
2021-06-08 16:59 |
Anonymous (not verified) |
66.188.136.150 |
John Sorrentino |
Proprietorship |
808 Dixie Dr. Enterprise, AL 36330 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
John Sorrentino |
kschumacher@tricorinsurance.com |
Enterprise |
Coffee |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Sorrentino |
kschumacher@tricorinsurance.com |
Same |
Enterprise |
Coffee |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
324 |
2020-11-20 09:08 |
Anonymous (not verified) |
71.39.227.238 |
County-Line Construction, LLC |
Limited Liability Company |
314 NE 2nd St, Panora, IA 50216 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-20 |
John Steve Vogel |
thevogels@netins.net |
Panora |
Guthrie |
Iowa |
Steve Phillips |
Abbey Luellen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Steve Vogel |
thevogels@netins.net |
Owner |
Panora |
Guthrie |
Iowa |
Steve Phillips |
Abbey Luellen |
Signed |
726 |
2021-11-05 14:39 |
Anonymous (not verified) |
174.198.66.202 |
John Stoltzfus JM Tile LLC |
Limited Liability Company |
Wellman, Ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-19 |
John Stoltzfus |
installation@bachmeiercarpetone.com |
Wellman |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Stoltzfus |
installation@bachmeiercarpetone.com |
Self |
Wellman |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1162 |
2022-06-23 08:17 |
Anonymous (not verified) |
172.58.122.231 |
John lewis |
Limited Liability Company |
2130 lay 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. |
2022-06-23 |
John trick lewis |
Johnericklewis@gmail.com |
Des moines |
polk |
iowa |
Robert Rodriguez |
Penny scroggins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John lewis |
Johnericklewis@gmail.com |
co worker |
Des moines |
polk |
iowa |
Robert Rodriguez |
Penny scoggins |
Signed |
1259 |
2022-08-15 13:47 |
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 |
Johnathan Scott |
karma27895@gmail.com |
East Moline |
Rock Island |
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 |
1909 |
2023-11-15 12:27 |
Anonymous (not verified) |
94.188.207.228 |
CHAR-LES BUILDINGS LLC |
Limited Liability Company |
14633 7TH AVE NW, ANDOVER MN 55304 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
JOHNNY CHAVEZ CHAVEZ |
charlychavez151@gmail.com |
ANDOVER |
ANOKA |
MINNESOTA |
ALEIDA LEE |
DANY JIMBO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOHNNY CHAVEZ CHAVEZ |
charlychavez151@gmail.com |
OWNER |
ANDOVER |
ANOKA |
MINNESOTA |
ALEIDA LEE |
DANY JIMBO |
Signed |
1315 |
2022-09-20 13:11 |
Anonymous (not verified) |
173.17.128.203 |
Leaffilter |
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. |
2022-09-20 |
Johnny Coker |
johnnycoker36@gmail.com |
Altoona |
Polk |
Iowa |
Travis Klapproth |
Emilie Klapproth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LeafFilter |
support@leafhome.com |
Sub contractor |
Grimes |
Polk |
Iowa |
Travis Klapproth |
Emilie Klapproth |
Signed |
433 |
2021-03-12 20:47 |
Anonymous (not verified) |
173.28.1.65 |
HomeTeam painting llc |
Limited Liability Company |
3810 Amherst Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-12 |
Johnny ollin |
johnnyollin@gmail.com |
DesMoines |
Polk |
IOWA |
David Carney |
Chad Winslow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Johnny ollin |
johnnyollin@gmail.com |
Myself |
DesMoines |
Polk |
IOWA |
David Carney |
Chad Winslow |
Signed |
1598 |
2023-04-25 07:02 |
Anonymous (not verified) |
94.188.205.174 |
Johnny Pommer |
Limited Liability Company |
4125, E 30th 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. |
2023-04-25 |
Johnny Pommer |
bravojohnny@me.com |
Des Moines |
United states |
IA |
Johnny Pommer |
Kimberly pommer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Johnny Pommer |
bravojohnny@me.com |
Owner |
Des Moines |
United States |
IA |
Johnny Pommer |
Kimberly pommer |
Signed |
542 |
2021-06-16 07:26 |
Anonymous (not verified) |
173.23.202.34 |
Russell’s lawn & landscape |
Limited Liability Company |
285 robins rd, Hiawatha unit C16 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-16 |
Johnoy Khalil Russell |
johnoyjrrussell@gmail.com |
Hiawatha |
Linn |
Iowa |
Adrian pink |
Rupert Ellis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Johnoy Khalil russell |
johnoyjrrussell@gmail.com |
Owner |
Hiawatha |
Linn |
Iowa |
Rupert ellis |
Adrian pink |
Signed |
480 |
2021-04-14 15:58 |
Anonymous (not verified) |
65.103.82.36 |
Home Cleaning Services |
Proprietorship |
1448 w 13th 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. |
2020-01-01 |
Jolene Lyn Brown |
j@gmail.com |
davenport |
scott |
IA |
Jamie Swanson |
Andrew Swanson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jolene Brown |
j@gmail.com |
owner |
davenport |
Scott |
IA |
Jamie Swanson |
andrew Swanson |
Signed |
94 |
2020-03-18 13:18 |
Anonymous (not verified) |
174.243.114.80 |
Sogard Excavating |
Limited Liability Company |
2374 380th St, Jewell, IA 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-18 |
Jon A Sogard |
jsogard22@gmail.com |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sogard Excavating LLC |
jsogard22@gmail.com |
owner |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
1856 |
2023-09-29 13:18 |
Anonymous (not verified) |
94.188.205.166 |
MUESSIGMANN ENTERTAINMENT LLC |
Limited Liability Company |
906 2ND AVE SE 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. |
2023-09-27 |
JON MUESSIGMANN |
MUESSIGMANNENT@GMAIL.COM |
SPENCER |
CLAY |
Iowa |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JON MUESSIGMANN |
MUESSIGMANNENT@GMAIL.COM |
SELF |
SPENCER |
CLAY |
Iowa |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
991 |
2022-03-21 15:25 |
Anonymous (not verified) |
64.191.6.226 |
Wheeler Painting |
Proprietorship |
102 Maple Circle Waverly Iowa 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. |
2022-03-21 |
Jon Wheeler |
jon.wheeler67@gmail.com |
Waverly |
Bremer |
Iowa |
Jason Grant |
Richard Grant |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jon Wheeler |
jon.wheeler67@gmail.com |
Owner |
Waverly |
Bremer |
Iowa |
Jason Grant |
Richard Grant |
Signed |
1275 |
2022-08-19 13:40 |
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 |
Jonas Martinez |
jonasmartinez0202@icloud.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 |
1667 |
2023-05-29 22:31 |
Anonymous (not verified) |
94.188.207.226 |
All J Acres |
Limited Liability Company |
13522 120th Ave, Ottumwa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-26 |
Jonathan Bunt |
jonbunt@gmail.com |
Ottumwa |
Wapello |
IA |
James Williamson |
James Ash |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathan Bunt |
jonbunt@gmail.com |
Self |
Ottumwa |
Wapello |
IA |
James Williamson |
James Ash |
Signed |
1129 |
2022-05-26 13:34 |
Anonymous (not verified) |
172.58.227.18 |
Jonathan M Ramirez |
Proprietorship |
834 20th STREET SE. Cedar Rapids IA 53403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-26 |
Jonathan M Ramirez |
jon.hodgecma@gmail.com |
Cedar Rapids |
Linn |
IA |
Audrey Randle-EL |
Jeffrey M Ramirez Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathan Ramirez |
linncountyramirez@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Audrey Randle-EL |
Jeffrey Ramirez Jr |
Signed |
1130 |
2022-05-26 13:34 |
Anonymous (not verified) |
172.58.227.18 |
Jonathan M Ramirez |
Proprietorship |
834 20th STREET SE. Cedar Rapids IA 53403 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-26 |
Jonathan M Ramirez |
jon.hodgecma@gmail.com |
Cedar Rapids |
Linn |
IA |
Audrey Randle-EL |
Jeffrey M Ramirez Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathan Ramirez |
linncountyramirez@gmail.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Audrey Randle-EL |
Jeffrey Ramirez Jr |
Signed |
1289 |
2022-09-01 11:06 |
Anonymous (not verified) |
104.222.95.52 |
Alliant Personnel Resources |
Limited Liability Company |
619 N Carroll 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. |
2022-09-01 |
Jonathan Sturm |
Jon@AlliantPR.com |
Carroll, IA |
Carroll County |
IA |
Sara Beiter |
Austin Scott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jon Sturm |
Jon@AlliantPR.com |
Owner |
Carroll, IA |
Carroll County |
Iowa |
Sara Beiter |
Austin Scott |
Signed |
2135 |
2024-04-04 11:02 |
Anonymous (not verified) |
94.188.207.227 |
Jonathan Warner |
Proprietorship |
420 16th Avenue, East Moline, IL 61244, 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. |
2024-04-04 |
Jonathan Warner |
bsguttersllc@gmail.com |
East Moline, IL |
Moline |
Illinois |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Johnson |
MO |
Jordan Loyd |
Cody Dunbar |
Signed |
1850 |
2023-09-20 16:28 |
Anonymous (not verified) |
94.188.207.225 |
JB DOCK SERVICE |
Limited Liability Company |
1313 34TH ST 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. |
2023-09-20 |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
370 |
2021-01-22 14:23 |
Anonymous (not verified) |
71.39.227.238 |
Jonathon McClure |
Proprietorship |
25059 R Ave, 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. |
2021-01-22 |
Jonathon McClure |
mcclure.jonathon@gmail.com |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathon McClure |
mcclure.jonathon@gmail.com |
Self |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
352 |
2021-01-11 12:56 |
Anonymous (not verified) |
66.188.136.150 |
Jonathon Pearson |
Proprietorship |
3001 Desoto St. Shreveport, LA 71103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Jonathon Pearson |
kschumacher@tricorinsurance.com |
Shreveport |
Caddo |
LA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathon Pearson |
kschumacher@tricorinsurance.com |
Same |
Shreveport |
Caddo |
LA |
Russell Masartis |
Nancy Wortley |
Signed |
1839 |
2023-09-12 11:22 |
Anonymous (not verified) |
94.188.205.167 |
J.S. Reeves Consulting LLC |
Limited Liability Company |
1610 1st Ave, Perry, IA 50220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-12 |
joni Sue Reeves |
jonisreeves@att.net |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joni Sue Reeves |
jsreeves67@gmail.com |
Same |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
1827 |
2023-09-01 15:45 |
Anonymous (not verified) |
94.188.205.166 |
Roush construction |
Proprietorship |
Roush construction (self) |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-01 |
Jontie Steven roush |
natycady@hotmail.com |
Indianola |
Warren |
Iowa |
Tara murphy |
Mike ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jontie Steven roush |
natycady@hotmail.com |
Same person. |
Indianola |
Warren |
Iowa |
Tara murphy |
Mike ryerson |
Signed |
1958 |
2023-12-15 12:26 |
Anonymous (not verified) |
94.188.205.168 |
Big & Steinke Construction |
Limited Liability Company |
1737 B Avenue NE Cedar Rapids, Iowa 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. |
2023-12-15 |
Jordan Bigbee |
bigandsteinkeconstruction@gmail.com |
Cedar Rapids |
Iowa |
United States |
Zachary Steinke |
Taylor Bigbee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zachary Steinke |
bigandsteinkeconstruction@gmail.com |
Owner |
Cedar Rapids |
Iowa |
United States |
Jordan Bigbee |
Taylor Bigbee |
Signed |
731 |
2021-11-09 14:08 |
Anonymous (not verified) |
166.181.87.107 |
Leaf Filter North |
Limited Liability Company |
3060 SE Grimes Blvd, STE 100 Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-09 |
Jordan Cunningham |
jcunnsalvage@gmail.com |
Baxter |
Jasper |
Iowa |
Karen Cunningham |
Makenzie Raridon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan McIlhon |
mmcilhon@leaffilter.com |
Office Manager |
Grimes |
Polk |
Iowa |
Karen Cunningham |
Makenzie Raridon |
Signed |
1280 |
2022-08-22 15:48 |
Anonymous (not verified) |
104.222.83.187 |
Cabinet Kulture LLC |
Limited Liability Company |
927 N. West St. Carroll, 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 |
Jordan Ellis |
cabinetkulture@gmail.com |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cabinet Kulture LLC |
cabinetkulture@gmail.com |
Same person |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
1308 |
2022-09-14 21:25 |
Anonymous (not verified) |
166.196.110.63 |
Anhalt Trucking |
Limited Liability Company |
Canby MN |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Jordan J Anhalt |
anhalt.trucking@gmail.com |
Canby |
MN |
United States |
Ashley Anhalt |
Jace Anhalt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan J Anhalt |
anhalt.trucking@gmail.com |
Same |
Canby |
MN |
United States |
Ashley Anhalt |
Jace Anhalt |
Signed |
1464 |
2023-02-17 15:05 |
Anonymous (not verified) |
94.188.205.166 |
Jordan Walkup |
Proprietorship |
5751 NE 22nd 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. |
2023-02-17 |
Jordan Walkup |
jordanw@bigroofing515.com |
Windsor Heights |
Polk |
IA |
Sarah Walkup |
Steve Bieghler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Walkup |
jordanw@bigroofing515.com |
Self |
Windsor Heights |
Polk |
IA |
Sarah Walkup |
Steve Bieghler |
Signed |
2029 |
2024-02-07 09:51 |
Anonymous (not verified) |
94.188.207.223 |
Jorge Llanos |
Proprietorship |
3304 Le Mesa Way, South Sioux City, 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. |
2024-02-07 |
Jorge Llanos |
jorge.llanos123708@gmail.com |
South Sioux City |
Dakota |
Nebraska |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Acosta |
macosta@leafhome.com |
Recruiter |
Sioux Falls |
Minnehaha |
South Dakota |
Cody Dunbar |
Jordan Nisiewicz |
Signed |
618 |
2021-08-23 15:17 |
Anonymous (not verified) |
173.17.131.91 |
Leaffilter North of Iowa, LLC |
Proprietorship |
5650 NW 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. |
2021-08-23 |
Jorge Meraz |
jmaraz961@gmail.com |
2906 e madison avenue |
Des moines |
IA |
Jisel chaves |
Melvin arevalo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jorge meraz |
jmeraz961@gmail.com |
Self |
Des moines |
Des moine |
IA |
Jusel chavez |
Melvin arevalo |
Signed |
747 |
2021-11-12 15:08 |
Anonymous (not verified) |
75.162.157.80 |
Unique Hardwood Floors, LLC |
Limited Liability Company |
1202 Army Post Rd. 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. |
2021-11-12 |
Jose A Dominguez Lopez |
uniquefloorsdmi@gmail.com |
Des Moines |
USA |
Iowa |
Elizabeth Dominguez |
Liliana Sanchez Gutierrez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose A Dominguez Lopez |
uniquefloorsdmi@gmail.com |
Owner |
Des Moines |
USA |
Iowa |
Elizabeth Dominguez |
Liliana Sanchez Gutierrez |
Signed |
1802 |
2023-08-15 15:23 |
Anonymous (not verified) |
94.188.205.174 |
NORTH STARS, LLC |
Limited Liability Company |
4374 STATE ST STE 2 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. |
2023-08-15 |
JOSE A DURAN MORALES |
northstarsllcmn@gmail.com |
BETTENDORF |
USA |
IOWA |
ARMANDO DURAN |
LILIANA SANCHEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NORTH STARS, LLC |
northstarsllcmn@gmail.com |
BUSINESS OWNER |
BETTENDORF |
USA |
IOWA |
LILIANA SANCHEZ |
ARMANDO DURAN |
Signed |
245 |
2020-08-25 15:20 |
Anonymous (not verified) |
107.77.207.111 |
J&R cleaning co LLC |
Limited Liability Company |
14300 Holcomb ave #210 urbandale ia. 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-25 |
José A salas romero |
chinito80sr@hotmail.com |
Desmoines |
Polk |
Iowa |
Ana López |
Jesus gonzales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
José romero |
chinito80sr@hotmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Ana lopez |
Jesus Gonzales |
Signed |
2151 |
2024-04-15 14:42 |
Anonymous (not verified) |
94.188.207.227 |
Jose Acuna |
Proprietorship |
1015 East Main Street, Belmond, IA 50421, 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. |
2024-04-15 |
Jose Acuna |
Joseacuna@gmail.com |
Belmond, IA |
Wright |
Iowa |
Jordan Loyd |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Johnson |
Missouri |
Jordan Loyd |
Cody Dunbar |
Signed |
1523 |
2023-03-18 13:15 |
Anonymous (not verified) |
94.188.207.223 |
Aguilera’s Lawn Care LLC |
Limited Liability Company |
827 17th Street Southeast, Altoona, 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. |
2023-03-18 |
Jose Aguilera |
aguileramowing20@gmail.com |
Altoona |
IA |
United States |
Heather Aguilera |
Heather Aguilera |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Aguilera |
aguileramowing20@gmail.com |
Self- owner |
Altoona |
IA |
United States |
Heather Aguilera |
Heather Aguilera |
Signed |
494 |
2021-04-22 12:41 |
Anonymous (not verified) |
173.18.16.129 |
Unique Drywall Finishing LLC |
Limited Liability Company |
509 E 26th 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. |
2021-04-22 |
jose angel chavez |
uniquewal@yahoo.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Angel Chavez |
uniquewal@yahoo.com |
owner |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
978 |
2022-03-15 12:42 |
Anonymous (not verified) |
173.24.17.213 |
Jose Antonio Hernández Tobar |
Limited Liability Company |
219 Huisman 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. |
2022-03-15 |
Jose Antonio Hernandez Tobar |
josehernanr5@icloud.com |
Marshalltown |
Marshall |
Iowa |
Cindy Garcia Hernandez |
Jaquelin Garcia Barajas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Antonio Hernandez Tobar |
josehernanr5@icloud.com |
Self |
Marshalltown |
Marshall |
Iowa |
Cindy Garcia Hernandez |
Jaquelin Garcia Barajas |
Signed |
617 |
2021-08-23 13:58 |
Anonymous (not verified) |
172.58.84.152 |
Jose barrientos |
Proprietorship |
1844 n tony 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-08-23 |
Jose Barrientos |
70barrientos70@gmail.com |
Wichita |
Sedwick |
Kansas |
Roberto valle |
Juan lopez |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jose barrientos |
70barrientos70@gmail.com |
Employer |
Wichita |
Sedwick |
Kansas |
Vladimir faustino |
Rene Grande |
Signed |
1775 |
2023-08-03 09:37 |
Anonymous (not verified) |
94.188.207.227 |
J j builder llc |
Limited Liability Company |
2307 richland dr 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. |
2023-07-28 |
José Cruz Jasso balleza |
jassoprimo03@icloud.com |
Des moines |
Polk |
Iowa |
Jaime Rodrigues |
Mario ramos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Irving |
iibarra@centroinsurance.com |
Agent |
Des moines |
Polk |
Iowa |
Irving Ibarra |
Jaime Rodrigues |
Signed |
1450 |
2023-02-11 10:59 |
Anonymous (not verified) |
94.188.205.168 |
JOSE G OLIVAREZ |
Limited Liability Company |
1529 11TH ST DES MOINES 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. |
2023-02-11 |
JOSE G OLIVAREZ |
joseolivares742@gmail.com |
DES MOINES |
POLK |
IOWA |
SAMIR RAHMANOVIC |
SAMIR RAHMANOVIC |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
none |
joseolivares742@gmail.com |
none |
DES MOINES |
POLK |
IOWA |
samir rahmanovic |
samir rahmanovic |
Signed |
239 |
2020-08-20 14:47 |
Anonymous (not verified) |
173.23.150.218 |
Gaytan Framing LLC |
Limited Liability Company |
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. |
2020-08-20 |
Jose Gaytan |
jose1988.jg8@gmail.com |
Des Moines |
Polk |
Iowa |
Misael Balleza |
Carla Gaytan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Gaytan Ruiz |
jose1988.jg8@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Misael Balleza |
Carla Gaytan |
Signed |
1228 |
2022-07-26 10:06 |
Anonymous (not verified) |
173.23.93.3 |
Gaytan Framing LLC |
Limited Liability Company |
2418 East 37th 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. |
2022-07-26 |
Jose Gaytan |
jose1988.jg8@gmail.com |
Des Moines |
Polk |
United States |
CARLA C. GAYTAN |
Juan Franco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Gaytan |
jose1988.jg8@gmail.com |
self |
Des Moines |
IA |
United States |
CARLA C. GAYTAN |
Juan franco |
Signed |
1745 |
2023-07-13 16:20 |
Anonymous (not verified) |
94.188.205.174 |
Gaytan Framing LLC |
Limited Liability Company |
4745 NE 27th 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. |
2023-07-13 |
Jose Gaytan Ruiz |
jose1988.jg8@gmail.com |
Des Moines |
Polk |
Des Moines |
Erwin Quintanilla |
Misael Balleza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Gaytan Ruiz |
jose1988.jg8@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Edwin Quintanilla |
Misael Balleza |
Signed |
367 |
2021-01-21 14:18 |
Anonymous (not verified) |
107.117.168.117 |
1105 Wade St |
Proprietorship |
1105 WADE 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. |
2021-01-03 |
Jose J Castillo |
Jonathancas782@gmail.com |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose J Castillo |
Jonathancas782@gmail.com |
Owner |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
463 |
2021-04-06 21:34 |
Anonymous (not verified) |
173.23.145.187 |
LANTZ ELITE CARPENTRY & CONSTRUCTION INC |
Limited Liability Company |
1980 NW 94th St, Ste C 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. |
2021-01-01 |
Jose J. Castillo |
castillojosejonathan7@gmail.com |
Des Moines |
Polk |
IOWA |
PERLA LANDAVERDE |
ALMA J. GAYTAN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOSE J. CASTILLO |
CASTILLOJOSEJONATHAN7@GMAIL.COM |
self |
Des Moines |
Iowa |
IOWA |
PERLA LANDAVERDE |
ALMA J. GAYTAN |
Signed |
1638 |
2023-05-11 07:33 |
Anonymous (not verified) |
94.188.205.177 |
HV Drywall LLC |
Proprietorship |
1991 Holiday Rd, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Jose Jesus Hernandez |
jh80292@gmail.com |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Jesus Hernandez |
jh80292@gmail.com |
self |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
171 |
2020-06-01 16:17 |
Anonymous (not verified) |
99.203.98.130 |
Jose Jurado |
Limited Liability Company |
3825 NE 43rd 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. |
2020-06-01 |
Jose Jurado |
trustedroofingllc@gmail.com |
Des Moines |
Polk |
IOWA |
Sterling Bean |
Sigifredo Corral |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Jurado |
trustedroofingllc@gmail.com |
Marcos Jurado |
Des Moines |
Polk |
IOWA |
Sterling Bean |
Sigifredo Corral |
Signed |
2015 |
2024-02-01 08:26 |
Anonymous (not verified) |
94.188.207.223 |
Salazar Builders inc |
Proprietorship |
29175 365th st van meter 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. |
2024-02-01 |
José Luis ángeles Salazar |
salazarbuilders15@gmail.com |
Van meter ia |
Dallas |
Iowa |
Adam Paul Boge |
Lance Owen Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Luis angeles Salazar |
salazarbuilders15@gmail.com |
Sub contractor |
Van meter |
Dallas |
Iowa |
Adam Paul Boge |
Lance Owen Webster |
Signed |
1687 |
2023-06-12 16:23 |
Anonymous (not verified) |
94.188.207.229 |
Jose Manuel Sanchez Loreto |
Proprietorship |
108 North Hawthorn Drive Altoona, Iowa 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-12 |
Jose Manual Sanzhez Loreto |
jjanna1226@gmail.com |
Altoona |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Manuel Sanchez Loreto |
jjana1226@gmail.com |
self |
Altoona |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
2123 |
2024-03-28 10:42 |
Anonymous (not verified) |
94.188.207.229 |
J&J Masonry |
Proprietorship |
2519 Poppleton Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-28 |
Jose Marroquin |
drakkarhr7@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Marroquin |
drakkarhr7@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
1310 |
2022-09-15 12:34 |
Anonymous (not verified) |
75.162.181.22 |
JCC CONSTRUCTION, LLC |
Limited Liability Company |
823 E 22ND CT. 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. |
2022-09-15 |
JOSE MAURICIO CARDOZA |
WILSONCARDOZA1985@GMAIL.COM |
DES MOINES |
USA |
IOWA |
WILSON CARDOZA |
JULIO CARDOZA |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOSE MAURICIO CARDOZA |
WILSONCARDOZA1985@GMAIL.COM |
Company Owner |
Des Moines |
USA |
Iowa |
Wilson Cardoza |
Julio Cardoza |
Signed |
1817 |
2023-08-24 12:29 |
Anonymous (not verified) |
94.188.207.223 |
Global Roofing LLC |
Limited Liability Company |
504 Heritage Rd 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. |
2023-08-20 |
Jose Rafael Delgado Marin |
grjrd808504@outlook.com |
Cedar Falls |
Black Hawk |
Iowa |
Noemi Guerrero |
Andres B Montoya |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Rafael Delgado |
grjrd808504@outlook.com |
member |
Cedar Falls |
Black Hawk |
Iowa |
Noemi Guerrero |
Andres B Montoya |
Signed |
1244 |
2022-08-08 09:28 |
Anonymous (not verified) |
174.255.1.240 |
Jose Rivera |
Proprietorship |
6100 w lincoln way lot 25 Ames lA 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-08 |
Jose Rivera |
josechepe91@icloud.com |
Ames |
Boone |
lowa |
Jose Rivera |
Jose Rivera |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tim |
Tim@thefortress.net |
Friends |
Ames |
Boone |
Iowa |
Eliazar Martinez |
Sabino Díaz |
Signed |
1245 |
2022-08-08 09:28 |
Anonymous (not verified) |
174.255.1.240 |
Jose Rivera |
Proprietorship |
6100 w lincoln way lot 25 Ames lA 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-08 |
Jose Rivera |
josechepe91@icloud.com |
Ames |
Boone |
lowa |
Jose Rivera |
Jose Rivera |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tim |
Tim@thefortress.net |
Friends |
Ames |
Boone |
Iowa |
Eliazar Martinez |
Sabino Díaz |
Signed |
661 |
2021-10-01 09:00 |
Anonymous (not verified) |
71.34.184.201 |
Jose Tavares |
Proprietorship |
1175 Office Park Rd Apt 109 WDM 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. |
2021-09-24 |
Jose Tavares |
deb@piciowa.com |
1175 Office Park Rd Apt 109 WDM IA 50266 |
Polk |
Iowa |
Martin Pinon |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Tavares |
deb@piciowa.com |
self |
WDM |
Polk |
IA |
Martin Pinon |
Debra Stratton |
Signed |
1741 |
2023-07-12 09:38 |
Anonymous (not verified) |
94.188.207.230 |
Jose Tavares |
Proprietorship |
1175 Office Park Road Apt 109 WDM 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. |
2021-09-28 |
Jose Tavares |
deb@piciowa.com |
WDM |
Polk |
IA |
Martin Pin on |
Deb Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Tavares |
deb@piciowa.com |
self |
WDM |
Polk |
IA |
Martin Pinon |
Deb Stratton |
Signed |
666 |
2021-10-07 08:12 |
Anonymous (not verified) |
208.126.166.149 |
Toribio Construction LLC |
Limited Liability Company |
107 W Maxson 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. |
2020-10-07 |
Jose Toribio |
osorioabigail0224@gmail.com |
West Liberty |
Muscatine |
IA |
Anthony Johnson |
Abigail Osorio |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Toribio |
osorioabigail0224@gmail.com |
Owner |
West Liberty |
Muscatine |
IA |
Anthony Johnson |
Abigail Osorio |
Signed |
1810 |
2023-08-21 10:18 |
Anonymous (not verified) |
94.188.207.224 |
Vicente McCain |
Proprietorship |
524 panama st Nashua |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2023-08-20 |
Jose V Mccain |
Vic_mccain@yahoo.com |
Nashua |
IA |
United States |
Rafael McCain |
Jessica McCain |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jose V Mccain |
Vic_mccain@yahoo.com |
Brother |
Nashua |
IA |
United States |
Rafael McCain |
Jessica McCain |
Signed |
443 |
2021-03-22 13:22 |
Anonymous (not verified) |
167.127.218.244 |
Romero Carpentry |
Proprietorship |
2060 King Ave, Apt 19, Des Moines, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-22 |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Des moines |
Polk |
United States |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose Wilber Romero Batres |
Josew.batres@icloud.com |
Self |
Des Moines |
Polk |
Iowa |
Gabriela Cecibel Chicas |
David Antonio Barrera Serrano |
Signed |
2184 |
2024-04-26 15:03 |
Anonymous (not verified) |
94.188.205.166 |
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. |
2024-04-15 |
Joseph Abrahamson |
abrahamsonjd95@gmail.com |
Readlyn |
Bremer |
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 |
Blackhawk |
Iowa |
Colton Blue |
Kari Houle |
Signed |
458 |
2021-04-05 11:59 |
Anonymous (not verified) |
66.188.136.150 |
Joseph Chance |
Proprietorship |
815 Richards Dr. Shorewood, IL 60404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Joseph Chance |
kschumacher@tricorinsurance.com |
Shorewood |
Will |
IL |
Russell Masartis |
Amanda Seeberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Chance |
kschumacher@tricorinsurance.com |
Same |
Shorewood |
Will |
IL |
Russell Masartis |
Amanda Seeberger |
Signed |
118 |
2020-04-13 11:48 |
Anonymous (not verified) |
173.26.152.222 |
Society of St. Vincent de Paul, District Council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Joseph D. Sobczyk |
joczyk@aol.com |
Cedar Falls |
Black Hawk |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
self |
Cedar Falls |
Black Hawk |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
2023 |
2024-02-05 21:11 |
Anonymous (not verified) |
94.188.205.176 |
Joey Pohlen |
Proprietorship |
4552 400th St. Hospers, Iowa 51238 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-05 |
Joseph Dale Pohlen |
joey.pohlen18@gmail.com |
Hospers |
Sioux |
Iowa |
Joseph Clarence Pohlen |
Steven Laurence Auchstetter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Dale Pohlen |
joey.pohlen18@gmail.com |
owner |
Hospers |
Sioux |
Iowa |
Joseph Clarence Pohlen |
Steven Laurence Auchstetter |
Signed |
582 |
2021-07-22 15:14 |
Anonymous (not verified) |
173.24.111.218 |
Joseph Davis |
Proprietorship |
7257 Valley Dr, bettendorf ia 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Joseph Davis |
jtigerd@live.com |
Bettendorf |
Scott |
IA |
Jacob nagel |
Nick brewer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Davis |
jtigerd@live.com |
Agent |
Bettendorf |
IA |
IA |
Jacob nagel |
Nick brewer |
Signed |
1254 |
2022-08-14 09:00 |
Anonymous (not verified) |
172.225.140.185 |
Joe Forret |
Limited Liability Company |
18211 270st Adel Iowa 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. |
2022-08-14 |
Joseph Edward Forret |
joeforret@icloud.com |
Adel |
Dallas |
Iowa |
Bre Forret |
Seth Slater |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Edward Forret |
joeforret@icloud.com |
None |
Adel |
Dallas |
Iowa |
Bre forret |
Seth Slater |
Signed |
1505 |
2023-03-07 23:14 |
Anonymous (not verified) |
94.188.207.229 |
Harbinger Consultants LLC |
Limited Liability Company |
2333 SW Plaza Pkwy, #324, 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. |
2023-03-06 |
Joseph French |
joey@harbinger.finance |
Ankeny |
Polk |
Iowa |
Sawyer Mueller |
Kenneth French |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph French |
joey@harbinger.finance |
Principal |
Ankeny |
Polk |
Iowa |
Sawyer Mueller |
Kenneth French |
Signed |
1594 |
2023-04-24 10:06 |
Anonymous (not verified) |
94.188.205.175 |
Joseph Hatton |
Proprietorship |
85 Cardinal Ave, Atkins , 52206, 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. |
2023-04-24 |
Joseph Hatton |
joeyh697@gmail.com |
Atkins |
Benton 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 |
483 |
2021-04-16 10:47 |
Anonymous (not verified) |
204.155.61.217 |
Joseph Jones DBA Jones Sealcoating and Asphalt Repair |
Limited Liability Company |
1033 Hummingbird 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. |
2021-04-16 |
Joseph Jones |
iscrapcu@yahoo.com |
Waterloo |
Iowa |
Iowa |
Kyle Hildman |
Dan Sinnott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jospeh Jones |
iscrapcu@yahoo.com |
OWNER |
Waterloo |
Black Hawk |
IA |
Kyle Hildman |
Dan Sinnott |
Signed |
2138 |
2024-04-05 12:30 |
Anonymous (not verified) |
94.188.205.167 |
Joseph L Neighbors dba J L N Trucking |
Proprietorship |
5466 18th Ave Mount Auburn IA 52313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-05 |
Joseph L Neighbors |
robynne@cmbrown.net |
Mount Auburn |
Benton |
Iowa |
Sarah Svehla |
Angela Vangennip |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robynne Dawn Duvall |
robynne@cmbrown.net |
insurance agent |
Perryville |
Missouri |
Missouri |
Sarah Svehla |
Angela Vangennip |
Signed |
1502 |
2023-03-07 12:40 |
Anonymous (not verified) |
94.188.205.177 |
Joseph Martin |
Limited Liability Company |
P O Box 277 Lime Springs, 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. |
2022-04-18 |
Joseph Martin |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Al's Roofing LLC |
darrele@ciains.biz |
Member |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chrus Fye |
Signed |
1132 |
2022-05-28 12:01 |
Anonymous (not verified) |
166.181.81.175 |
Kamp Trucking LLC |
Limited Liability Company |
3411 doris 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. |
2022-05-28 |
Joseph Michael Kamp |
boss4z9@yahoo.com |
waterloo |
Iowa |
United States |
Glenn Harrison Bearbower |
April Ann Bearbower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Michael Kamp |
boss4z9@yahoo.com |
same person. I am an owner operator |
waterloo |
Iowa |
United States |
Glenn Harrison Bearbower |
April Ann Bearbower |
Signed |
595 |
2021-08-03 13:53 |
Anonymous (not verified) |
174.248.224.252 |
Joseph r cunningham dba freedom field services |
Proprietorship |
6285 n 67th ave w Baxter iowa 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Joseph r Cunningham jr. |
joecunningham1966@protonmail.com |
Baxter |
Jasper |
Iowa |
Chelsey Cunningham |
Chris Cort |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph r cunningham jr |
joecunningham1966@protonmail.com |
Me |
Baxter |
Jasper |
Iowa |
Chelsey cunningham |
Chris cort |
Signed |
650 |
2021-09-22 20:46 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services |
Limited Liability Company |
6285 n 67 ave w baxter iowa 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
owner |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
651 |
2021-09-22 21:05 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services LLC |
Limited Liability Company |
6285 n 67 ave w. BAXTER IOWA 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
owner |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
656 |
2021-09-25 09:20 |
Anonymous (not verified) |
173.20.172.87 |
Daugherty Construction LLC |
Limited Liability Company |
1985 SE Willow Brook Dr, Waukee, 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. |
2021-09-25 |
Joseph Ryan Daugherty |
jdaugherty1024@yahoo.com |
Waukee |
Dallas |
Iowa |
Sarah Lynn Daugherty |
Timothy Joe Daugherty |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daugherty Construction LLC |
jdaugherty1024@yahoo.com |
Owner/President |
Waukee |
Dallas |
Iowa |
Sarah Lynn Daugherty |
Timothy Joe Daugherty |
Signed |
40 |
2020-01-19 13:20 |
Anonymous (not verified) |
167.142.82.171 |
Arganbright Land Improvement LLC |
Limited Liability Company |
2440 Redwood Ave. Guthrie Center, IA 50115 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-19 |
Josh Arganbright |
josh@arganbrightlandimp.com |
Guthrie Center |
Guthrie |
IA |
Kim Bauer |
Tom Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Arganbright |
josh@arganbrightlandimp.com |
self |
Guthrie Center |
Guthrie |
IA |
Kim Bauer |
Tom Smith |
Signed |
547 |
2021-06-24 08:05 |
Anonymous (not verified) |
97.125.169.60 |
Tenant Improvement Services, LLC |
Limited Liability Company |
3011 Justin Drive, Urbandale, IA 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-24 |
Josh Chiles |
josh@tenantimprovementsiowa.com |
Des Moines |
Polk |
Iowa |
John Martin |
Johnny Holman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Chiles |
josh@tenantimprovementsiowa.com |
Member |
Des Moines |
Polk |
Iowa |
John Martin |
Johnny Holman |
Signed |
1581 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.177 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd 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. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1582 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.177 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd 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. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1583 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.166 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd 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. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1584 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.166 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd 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. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1585 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.167 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd 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. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1519 |
2023-03-16 09:15 |
Anonymous (not verified) |
94.188.205.176 |
Frommelt Logging LLC |
Limited Liability Company |
109 Great River Rd. Holy Cross IA 52053 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Josh Frommelt |
jfrommelt1987@gmail.com |
Holy Cross |
Clayton |
Iowa |
Staci Frommelt |
Mitzi Hoeger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Frommelt |
jfrommelt1987@gmail.com |
owner |
Holy Cross |
Clayton |
Iowa |
Staci Frommelt |
Mitzi Hoeger |
Signed |
1788 |
2023-08-07 18:32 |
Anonymous (not verified) |
94.188.205.168 |
Johnson Custom Paint & Design LLC |
Limited Liability Company |
1414 N 9TH 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. |
2023-08-07 |
Josh Johnson |
johnsoncustompaint@hotmail.com |
Fort Dodge |
Iowa |
United States |
JACKLYN JOHNSON |
Roger Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
owner |
Fort Dodge |
IA |
United States |
JACKLYN JOHNSON |
Roger Johnson |
Signed |
1219 |
2022-07-21 12:39 |
Anonymous (not verified) |
98.22.2.115 |
Keeling Services |
Proprietorship |
3190 SE 64th St, 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. |
2022-07-21 |
Josh keeling |
Joshuakeeling110@gmail.com |
Pleasant Hill |
Iowa |
United States |
Kali Keeling |
Matthew Keeling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Bond |
mbond@leaffilter.com |
Regional sales manager |
Grimes |
Polk |
Iowa |
Kali Keeling |
Matthew Keeling |
Signed |
766 |
2021-11-22 16:19 |
Anonymous (not verified) |
63.229.189.35 |
Tribal Tile, LLC |
Limited Liability Company |
1402 Ithaca Ave, Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Josh Loerzel |
joshloerzel@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Loerzel |
joshloerzel@gmail.com |
Self |
SPIRIT LAKE |
Dickinson |
IA |
Abigail Miles |
Alex Miles |
Signed |
1994 |
2024-01-23 14:35 |
Anonymous (not verified) |
94.188.207.229 |
Josh Oswald |
Proprietorship |
505 Eisenhower Rd., 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. |
2024-01-23 |
Josh Oswald |
jjoswald47@gmail.com |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOSHUA OSWALD |
jjoswald47@gmail.com |
Sole Proprietor |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
Signed |
724 |
2021-11-05 14:25 |
Anonymous (not verified) |
209.252.172.87 |
Josh Peterson |
Proprietorship |
121 Karen Drive, 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. |
(1) I am not electing the employers’ liability coverage. |
2020-06-15 |
Josh Peterson |
tanyataz@msn.com |
Williamsburg |
Iowa |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Peterson |
tanyataz@msn.com |
Self Employed |
Williamsburg |
Iowa |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
541 |
2021-06-15 07:04 |
Anonymous (not verified) |
63.224.181.101 |
Schultes Horticulture and Landscape LLC |
Limited Liability Company |
1444 42nd 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. |
2021-06-15 |
Josh Schultes |
schulteshort@gmail.com |
Des Moines |
Iowa |
United States |
Josh Schultes |
Josh Schultes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Schultes |
schulteshort@gmail.com |
Self |
Des Moines |
Iowa |
United States |
Josh Schultes |
Josh Schultes |
Signed |
1234 |
2022-08-01 16:55 |
Anonymous (not verified) |
50.80.97.166 |
Joshua Schumacher |
Proprietorship |
5801 timber creek rd 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 |
Josh Schumacher |
amjs2003@centurylink.net |
Cedar Rapids |
Iowa |
Iowa |
Karen Meroshek |
Philip McCurdy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Schumacher |
amjs2003@centurylink.net |
Self |
Cedar Rapids |
Iowa |
Iowa |
Katen Meroshek |
Philip McCurdy |
Signed |
1848 |
2023-09-19 10:20 |
Anonymous (not verified) |
94.188.207.226 |
Josh Woodworth |
Proprietorship |
16405 u.s. 67 milan il 61264 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-19 |
Josh woodworth |
joshwoodworth84@live.com |
milan |
Rock island |
Illinois |
Cody dunbar |
Jordan nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody dunbar |
cdunbar@leaffilter.com |
Install manager |
moline |
Rock island |
illinois |
Cody dunbar |
Jordan nisiewic |
Signed |
1544 |
2023-03-29 16:52 |
Anonymous (not verified) |
94.188.207.228 |
Live Wire Trucking |
Limited Liability Company |
109 E Marion 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. |
2023-03-29 |
Joshua Allen Moore |
livewiretruckingIA@gmail.com |
Sigourney |
Iowa |
United States |
Ethan Weber |
Dylan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Allen Moore |
livewiretruckingIA@gmail.com |
Owner |
Sigourney |
Iowa |
United States |
Ethan David Weber |
Dylan Jefferey Miller |
Signed |
590 |
2021-07-29 16:38 |
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 |
Joshua Arthur Soppe |
choiceagservices@gmail.com |
Manchester |
Delaware |
Iowa |
Dustin Fessler |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Arthur Soppe |
choiceagservices@gmail.com |
Owner |
Manchester |
Delaware |
Iowa |
Dustin Fessler |
Adam Reth |
Signed |
950 |
2022-03-04 19:58 |
Anonymous (not verified) |
173.26.94.212 |
JRH Services |
Limited Liability Company |
525 Third St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-04 |
Joshua Blakeslee |
jrhservicesiowa@outlook.com |
Evansdale |
Blackhawk |
IA |
Nicole Blakeslee |
Lois Riggleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Blakeslee |
jrhservicesiowa@outlook.com |
Owner |
Evansdale |
Blackhawk |
IA |
Nicole Blakeslee |
Lois Riggleman |
Signed |
93 |
2020-03-16 08:01 |
Anonymous (not verified) |
174.217.14.119 |
DOUBLE J CONTRACTING LLC |
Limited Liability Company |
18693 335TH LN, EARLHAM, IA 50072 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-16 |
JOSHUA D OSCARSON |
double-j-llc@outlook.com |
EARLHAM |
DALLAS |
IOWA |
Tim Hudson |
Kevin Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas Oscarson |
double-j-llc@outlook.com |
Business Manager |
Earlham |
Dallas |
Iowa |
Tim Hudson |
Kevin Gomez |
Signed |
2056 |
2024-02-24 08:17 |
Anonymous (not verified) |
94.188.207.230 |
C&C Property LLC |
Limited Liability Partnership |
PO Box 418 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-24 |
Joshua Darwin Wessel |
wesselclublambs@gmail.com |
Kiron |
Crawford |
IA |
Chad D Foust |
Chad A Tweeten |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Tweeten |
tweeten@hotmail.com |
Barn Manager 1099 employee |
Eagle grove |
Wright |
Iowa |
Chad Tweeten |
Chad Foust |
Signed |
746 |
2021-11-11 19:26 |
Anonymous (not verified) |
166.181.87.101 |
Joshua Duncan |
Proprietorship |
2237 west high street 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. |
2021-11-11 |
Joshua Duncan |
Jduncan8669@gmail.com |
Davenport |
Scott |
Iowa |
Megan Ward |
Joseph Duncan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan Ward |
megward1986@gmail.com |
Fiancé |
Davenport |
Scott |
Iowa |
Megan Ward |
Joseph Duncan |
Signed |
1441 |
2023-02-06 14:37 |
Anonymous (not verified) |
69.40.94.166 |
ESW CONSTRUCTION INC |
Partnership |
35 HIGHWAY 22, KESWICK IA 50136 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
JOSHUA EDMUNDSON |
payten@iowacropservice.com |
KESWICK |
KEOKUK |
IOWA |
JULIE WHITE |
REBECCA APPLEGET |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BARBARA EDMUNDSON |
barb@iowacropservice.com |
agent |
SIGOURNEY |
KEOKUK |
IOWA |
JULIE WHITE |
REBECCA APPLEGET |
Signed |
1590 |
2023-04-21 07:10 |
Anonymous (not verified) |
94.188.205.168 |
Diamond Spray Foam & Coatings LLC |
Limited Liability Company |
19024 345th St, Forest City, IA 50436 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-21 |
Joshua G Diamond |
dsfinsulation@gmail.com |
Forest City |
Iowa |
United States |
Greg Diamond |
Renee Diamond |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua G Diamond |
dsfinsulation@gmail.com |
Owner |
Forest City |
Iowa |
United States |
Greg Diamond |
Renee Diamond |
Signed |
1665 |
2023-05-27 17:41 |
Anonymous (not verified) |
94.188.205.175 |
Diamond Spray Foam and Coatings LLC |
Limited Liability Company |
19024 345th St, Forest City, IA 50436 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-27 |
Joshua Gregory Diamond |
dsfinsulation@gmail.com |
Forest City |
Winnebago |
IA |
Brett Busenitz |
Bret Guggisburg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Gregory Diamond |
dsfinsulation@gmail.com |
Owner |
Forest City |
Winnebago |
IA |
Brett Busenitz |
Bret Guggisburg |
Signed |
112 |
2020-04-07 12:16 |
Anonymous (not verified) |
173.27.33.108 |
Josh Alley Siding |
Proprietorship |
205 N Oak St. Davis City, IA 50065 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2018-04-10 |
Joshua H. Alley |
alley.josh@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Alley Siding |
alley.josh@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
1008 |
2022-03-25 15:15 |
Anonymous (not verified) |
174.192.130.230 |
Hill's Rehab &Landscape L.L.C |
Limited Liability Company |
3717 15th ave Moline Illinois 61365 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-25 |
Joshua hill |
joshuajameshill79@gmail.com |
Moline |
Rock Island |
Illinois |
Lindsay erin Hill |
NICOLE ann lear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua james hill |
joshuajameshill79@gmail.com |
President |
Moline |
Rock Island |
Illinois |
Lindsay Erin Hill |
NIcole ann lear |
Signed |
1342 |
2022-10-25 09:02 |
Anonymous (not verified) |
174.240.251.79 |
Mahieu excavation |
Proprietorship |
6140 n Lincoln ave 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. |
2022-10-25 |
Joshua j Mahieu |
ridinmytrain2@gmail.com |
Davenport |
Scott |
Iowa |
Mike Leon |
Joseph Koranda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua j Mahieu |
ridinmytrain2@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Mike Leon |
Joseph Koranda |
Signed |
1194 |
2022-07-08 13:12 |
Anonymous (not verified) |
174.45.15.103 |
307 Safety LLC |
Limited Liability Company |
9 Trinidad CT Gillette, WY 82716 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-08 |
Joshua Peter Tompkins |
JTompkins@307Safety.com |
Gillette |
Campbell |
Wyoming |
Paul Prather |
Jason Praus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Peter Tompkins |
JTompkins@307Safety.com |
Owner |
Gillette |
Campbell |
Wyoming |
Paul Prather |
Jason Praus |
Signed |
1209 |
2022-07-17 16:41 |
Anonymous (not verified) |
166.181.86.161 |
JustbelieveCreationsllc |
Limited Liability Company |
104 East Chestnut Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-17 |
Joshua Riera-Gomez |
josh.gomez.com@gmail.com |
Garnavillo |
IA |
United States |
Eric Jarman |
Jean brandt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Riera-Gomez |
josh.gomez.com@gmail.com |
Myself |
Garnavillo |
IA |
United States |
Eric jarman |
Jean brandt |
Signed |
426 |
2021-03-09 09:31 |
Anonymous (not verified) |
50.82.173.179 |
Joshua Strong DBA Watson Excavation |
Proprietorship |
202 Lewis St Bedford, IA 50833 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-03-09 |
Joshua Strong |
joshandtanyastrong@yahoo.com |
Bedford |
Taylor |
IA |
Maggie Jackson |
Shella Baldwin |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tanya Strong |
tanya@farmandhomellc.com |
Spouse |
Bedford |
IA |
United States |
Maggie Jackson |
Shella Baldwin |
Signed |
729 |
2021-11-05 15:25 |
Anonymous (not verified) |
209.252.172.87 |
Joshua Yoder S&S Window Treatments |
Proprietorship |
2555 Hwy 1 SW, Iowa City Iowa 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-20 |
Joshua Yoder |
installation@bachmeiercarpetone.com |
Iowa City |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Yoder |
installation@bachmeiercarpetone.com |
Owner |
Iowa City |
Johnson |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1347 |
2022-10-26 14:42 |
Anonymous (not verified) |
173.21.223.66 |
Mid American Roofing |
Limited Liability Company |
811 8th St Kalona IA 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-26 |
Josiah Hoyt |
midamericanroofing@gmail.com |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josiah Hoyt |
josiahhoyt@gmail.com |
Owner |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
2122 |
2024-03-28 10:15 |
Anonymous (not verified) |
94.188.205.169 |
Stone Villalobos LLC |
Limited Liability Company |
4231 Morton Ave 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. |
2024-03-28 |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
1732 |
2023-07-10 13:22 |
Anonymous (not verified) |
94.188.207.224 |
Jovan Guerrero |
Proprietorship |
2887 Jaden Lane Norwalk, Iowa 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-10 |
Jovan Guerrero |
deb@piciowa.com |
Norwalk |
Warren |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jovan Guerrero |
deb@piciowa.com |
self |
Norwalk |
Warren |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
1814 |
2023-08-23 13:57 |
Anonymous (not verified) |
94.188.207.229 |
Exclusive Solutions LLC dba Jovan Guerrero |
Limited Liability Company |
2887 Jaden Lane Norwalk, Iowa 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-10 |
Jovan guerrero dba Exclusive Solutions LLC |
deb@piciowa.com |
Norwalk |
Polk |
Ia |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jovan Guerrero dba Exclusive SOlutions LLC |
jovanguerrero29@gmail.com |
self |
Norwalk |
Poik |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
1366 |
2022-11-10 09:33 |
Anonymous (not verified) |
172.58.87.232 |
Blackstone Handy Services, LLC |
Limited Liability Company |
1807 B Avenue Northeast |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-10 |
jovan walton |
blackstonehandyservices@gmail.com |
Cedar Rapids |
IA |
United States |
Mekaylah K. Stevens |
Dominique T. Walton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jovan walton |
blackstonehandyservices@gmail.com |
Self |
Cedar Rapids |
Linn |
United States |
Mekaylah K. Stevens |
Dominique T. Walron |
Signed |
826 |
2022-01-10 12:26 |
Anonymous (not verified) |
104.128.43.204 |
Wolfman Trucking, LLC |
Limited Liability Company |
406 S Lawrence St, Bazine, KS 67516 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-10 |
JR Steckline |
wolfmantrucking317@gmail.com |
Bazine |
Ness |
Kansas |
James Babcock |
Darin Wittman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JR Steckline |
wolfmantrucking317@gmail.com |
Owner |
Bazine |
Ness |
Kansas |
James Babcock |
Darin Wittman |
Signed |
799 |
2021-12-15 11:48 |
Anonymous (not verified) |
74.84.79.78 |
Juan Martinez Slazar |
Proprietorship |
7085 Bloomfield Rd. Lot # 38 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-01 |
Juan A. Martinez Salazar |
juan50320@gmail.com |
Des Moines |
Polk |
Iowa |
Steve Young |
Logan Giudicessi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan A. Martinez Salazar |
juan50320@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Steve Young |
Logan Giudicessi |
Signed |
434 |
2021-03-15 10:52 |
Anonymous (not verified) |
107.77.161.51 |
Juan osorio |
Proprietorship |
3000 university ave ap. 5103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Juan alfredo osorio |
fredyyosorio89@gmail.com |
Wes des moines |
Polk |
IA |
Manuel osorio |
Mario borjas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan alfredo osorio ayala |
fredyyosorio89@gmail.com |
Owner |
Wes des moines |
Polk |
IA |
Manuel osorio |
Mario borjas |
Signed |
1339 |
2022-10-18 14:14 |
Anonymous (not verified) |
97.125.41.64 |
Juan Buenrostro |
Proprietorship |
2122 E 39th 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. |
2022-10-18 |
Juan Buenrostro |
juanjosebuenrostro@gmail.com |
Des Moines |
Polk |
IA |
Juan Buenrostro |
Kelly gonzalez buenrostro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan nisiewicz |
jnisiewicz@leafhome.com |
Regional recruiter |
Kansas City |
Clay |
Missouri |
Jordan nisiewicz |
Jordan loyd |
Signed |
1438 |
2023-02-03 14:23 |
Anonymous (not verified) |
173.18.22.217 |
Cruz Construction Company, LLC |
Proprietorship |
2105 Clark 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. |
2023-02-03 |
Juan Canseco Cruz |
jcruz2515@icloud.com |
Des Moines |
Polk |
Iowa |
Erick Schuldt |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Conseco Cruz |
jcruz2515@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Erick Schuldt |
Kelly Coluzzi |
Signed |
2137 |
2024-04-05 10:28 |
Anonymous (not verified) |
94.188.207.227 |
Innovationsgenc@gmail.com |
Limited Liability Company |
1134 20th 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. |
2024-04-05 |
Juan carlos Soto Deanda |
charlye2512penelope@gmail.com |
East Moline |
IL |
United States |
Deja Rivers |
Eric Schwab |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan carlos Soto Deanda |
charlye2512penelope@gmail.com |
Owner |
East Moline |
IL |
United States |
Deja Rivers |
Eric Schwab |
Signed |
2119 |
2024-03-27 14:27 |
Anonymous (not verified) |
94.188.205.169 |
juan garcia |
Proprietorship |
3359 Patrick Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-27 |
Juan Garcia |
garcia.stone2022@gmail.com |
omaha |
Douglas |
Nebraska |
Ashlee Virves |
Reyna Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Garcia |
garcia.stone2022@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Ashlee Virves |
Reyna Garcia |
Signed |
1109 |
2022-05-16 19:02 |
Anonymous (not verified) |
173.20.161.18 |
Juan Manuel Alvarez |
Proprietorship |
2011 1st 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. |
2022-05-16 |
Juan m. Alvarez |
nemen01@hotmail.com |
Perry |
IA |
IA |
Ashley lynch |
Omar Alvarez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan m. Alvarez |
nemen01@hotmail.com |
Juan |
Perry |
IA |
IA |
Ashley lynch |
Omar Alvarez |
Signed |
883 |
2022-02-02 14:07 |
Anonymous (not verified) |
104.201.67.178 |
Juan Monterde |
Proprietorship |
9235 Swanson 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. |
2022-01-01 |
Juan Monterded |
s.thomas@nationwideofficecare.com |
Cedar Rapids |
Linn |
Iowa |
Cory Shelton |
Scott D Thomas |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott D Thomas |
scottthomascpa@msn.com |
Consultant |
West Des Moines |
IA |
United States |
Rich Darr |
Mari Lopez |
Signed |
1739 |
2023-07-11 12:18 |
Anonymous (not verified) |
94.188.205.169 |
Innovators Construction LLC |
Limited Liability Company |
3230 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 |
Juan Ramírez |
info@jmdrywallonline.com |
Homestead |
Iowa |
Iowa |
Itali Ramírez |
Guadalupe Ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Guadalupe Ramirez |
info@jmdrywallonline.com |
Business partner |
Homestead |
Iowa |
Iowa |
Itali Ramírez |
Juan M Ramírez |
Signed |
78 |
2020-02-25 09:35 |
Anonymous (not verified) |
65.127.131.118 |
Rey Construction, LLC |
Proprietorship |
3317 Scott Ave Des Moines, iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-02 |
Juan Raymundo Hernandez |
reyano43@gmail.com |
Des Moines |
polk |
iowa |
Rigoberto Mayorga |
Y Bounv Quang |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Preferred Interior Construction INC dba PIC INC |
deb@piciowa.com |
PIC, INC-contractor, Rey Construction, LLC-subcontractor |
Altoona |
IA |
United States |
Martin Pinon |
Evan Bianchi |
Signed |
2194 |
2024-04-30 14:57 |
Anonymous (not verified) |
94.188.207.223 |
Juan Raymundo Hernandez |
Proprietorship |
3317 Scott Ave 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. |
2024-01-25 |
Juan Raymundo Hernandez |
deb@piciowa.com |
Des Moines |
Poik |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Raymundo Hernandez |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
1640 |
2023-05-11 07:42 |
Anonymous (not verified) |
94.188.205.168 |
Ibarra Drywall LLC |
Proprietorship |
1991 Holiday Rd, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Juan Reyes Ibarra |
juanreyes22031979@gmail.com |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Reyes Ibarra |
juanreyes22031979@gmail.com |
Self |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
2066 |
2024-02-29 15:27 |
Anonymous (not verified) |
94.188.207.230 |
Julian Abey |
Proprietorship |
4405 NW Abilene Road, 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. |
2024-02-29 |
Julian Abey |
Jabeyhpro@gmail.com |
Ankeny |
Polk |
IA |
Eric Ndifon |
Peter Gara |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Julian Abey |
Jabeyhpro@gmail.com |
Self |
Ankeny |
IA |
IA |
Eric Ndifon |
Peter Gara |
Signed |
1921 |
2023-11-22 12:14 |
Anonymous (not verified) |
94.188.205.177 |
Julie Drtina |
Proprietorship |
Cresco Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-22 |
Julie Drtina |
juliedrtina@hotmail.com |
Cresco |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Julie Drtina |
juliedrtina@hotmail.com |
self |
Cresco |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
634 |
2021-09-10 13:41 |
Anonymous (not verified) |
173.23.145.231 |
julio medina |
Proprietorship |
609 boyd 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. |
2021-09-10 |
julio medina |
medinajulio10001@gmail.com |
des moines |
polk |
iowa |
jose rivas |
Virginia Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Julio Medina |
medinajulio10001@gmail.com |
owner |
des moines |
polk |
iowa |
jose Rivas |
Virginia Gomez |
Signed |
597 |
2021-08-05 13:38 |
Anonymous (not verified) |
204.155.61.217 |
Haag Consulting LLC |
Limited Liability Company |
8602 E Kael Circle, Mesa, AZ 85207 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-05 |
Justin Haag |
haag.justin1@gmail.com |
Mesa |
unknown |
AZ |
DocuSign |
Ashley Kraft |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Haag |
haag.justin1@gmail.com |
Owner |
Mesa |
unknown |
AZ |
DocuSign |
Ashley Kraft |
Signed |
379 |
2021-02-01 14:02 |
Anonymous (not verified) |
166.181.84.117 |
Holker Construction LLC |
Limited Liability Company |
512 n 15th 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. |
2021-02-01 |
Justin Holker |
jjholker@gmail.com |
Adel |
Dallas |
Iowa |
Tyanna Holker |
Scot Baker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Holker |
jjholker@gmail.com |
Self |
Adel |
Dallas |
IA |
Tyanna Holker |
Scot Baker |
Signed |
125 |
2020-04-20 19:01 |
Anonymous (not verified) |
67.22.196.182 |
Driven School of Driving |
Limited Liability Company |
451 E 1st ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-20 |
Justin J. Franken |
drivenschoolofdriving@gmail.com |
Sioux Center |
Sioux |
IA |
Robyn Franken |
Gracyn Franken |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Franken |
drivenschoolofdriving@gmail.com |
Me |
Sioux Center |
Sioux |
IA |
Robyn Franken |
Gracyn Franken |
Signed |
1311 |
2022-09-15 16:49 |
Anonymous (not verified) |
174.235.213.195 |
JJ Jones contracting |
Limited Liability Company |
2413 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. |
2022-09-15 |
Justin Jones |
jjjonescontractingllc@gmail.com |
Cedar Falls |
Black Hawk |
IA |
Dahoni Jones |
Jerold Cemrick Jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Jones |
jjjonescontractingll@gmail.com |
Self |
Cedar Falls |
Black Hawk |
IA |
Dahoni Jones |
Jerold Cemrick Jones |
Signed |
481 |
2021-04-14 17:15 |
Anonymous (not verified) |
199.66.15.81 |
K3 Recycling |
Limited Liability Company |
601 W. 1st Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-14 |
JUSTIN KAPPELMAN |
justin@kappelmanappliance.com |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charlie Kappelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUSTIN KAPPELMAN |
justin@kappelmanappliance.com |
Same person |
Indianola |
IA |
IA |
Kristy Kappelman |
Charlie Kappelman |
Signed |
937 |
2022-02-25 11:55 |
Anonymous (not verified) |
174.242.226.43 |
K3 Recycling |
Limited Liability Company |
510 West 2nd Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-25 |
Justin Kappelman |
justin@kappelmanappliance.com |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Kappelman |
justin@kappelmanappliance.com |
Same |
Indianola |
Iowa |
Iowa |
Kristy Kappelman |
Charles Kappelman |
Signed |
559 |
2021-07-08 08:27 |
Anonymous (not verified) |
66.188.136.150 |
Justin Keplinger |
Proprietorship |
8671 Hamby Rd. Morris, AL 35116 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Justin Keplinger |
kschumacher@tricorinsurance.com |
Morris |
Jefferson |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Keplinger |
kschumacher@tricorinsurance.com |
Same |
Morris |
Jefferson |
AL |
Mitch Kemp |
Shuree Behr |
Signed |
246 |
2020-08-25 15:36 |
Anonymous (not verified) |
97.125.173.2 |
MPT plumbing |
Limited Liability Company |
4616 147th 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. |
2020-08-25 |
justin lee tigges |
tplumbing3@aol.com |
urbandale |
dallas |
iowa |
insurance is a scam |
I would get a different issurance company |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
grinnell mutual |
lori@grinnellmutual.com |
insurance agent |
i dont know |
I don't know |
iowa |
what a pain in the ass |
This makes no sense |
Signed |
364 |
2021-01-14 13:46 |
Anonymous (not verified) |
173.31.147.225 |
JMAHER LLC |
Limited Liability Company |
907 4TH 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. |
2021-01-14 |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1504 |
2023-03-07 18:38 |
Anonymous (not verified) |
94.188.207.227 |
Mathias Heating & Cooling |
Limited Liability Company |
1449 19th Pl 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. |
2023-03-07 |
Justin Mathias |
emathiasj@gmail.com |
West Des Moines |
Polk |
Iowa |
Jesse Parker |
Jeff Boucher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Mathias |
emathiasj@gmail.com |
Member |
West Des Moines |
Polk |
Iowa |
Jesse Parker |
Jeff Boucher |
Signed |
850 |
2022-01-20 14:03 |
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 |
Justin Mehmen |
cmins_re@mchsi.com |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Mehmen |
cmins_re@mchsi.com |
Member of LLC |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
851 |
2022-01-20 14:10 |
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 |
Justin Mehmen |
cmins_re@mchsi.com |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Mehmen |
cmins_re@mchsi.com |
Member of LLC |
Parkersburg |
Butler |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
952 |
2022-03-05 18:23 |
Anonymous (not verified) |
108.59.100.21 |
Heaven Sent PC LLC |
Limited Liability Company |
604 Allamakee St, 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. |
2021-04-01 |
Justin Piggott |
heavensentpetcremation@gmail.com |
Waukon |
Allamakee |
Iowa |
Kaia Piggott |
Jane M Regan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Piggott |
heavensentpetcremation@gmail.com |
Member of LLC |
Waukon |
Allamakee |
Iowa |
Kaia Piggott |
Jane M Regan |
Signed |
2144 |
2024-04-10 14:23 |
Anonymous (not verified) |
94.188.205.176 |
Heaven Sent PC LLC |
Limited Liability Company |
604 Allamakee 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. |
2024-04-10 |
Justin PIggott |
heavensentpetcremation@gmail.com |
Waukon |
Allamakaee |
IA |
Jane M Regan |
Nancy Bechtel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Piggott |
heavensentpetcremation@gmail.com |
LLC Member |
Waukon |
Allamakee |
IA |
Jane M Regan |
Nancy Bechtel |
Signed |
1460 |
2023-02-16 12:36 |
Anonymous (not verified) |
94.188.205.174 |
Certified Septic Service |
Proprietorship |
2121 Rodeo ave monroe iowa 50170 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-16 |
Justin Rozendaal |
jusroz12@gmail.com |
Monroe |
Jasper |
Iowa |
Justin Rozendaal |
Miranda Rozendaal |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Rozendaal |
certifiedseptic@gmail.com |
Self |
Monroe |
Jasper |
Iowa |
Justin Rozendaal |
Miranda Rozendaal |
Signed |
968 |
2022-03-11 15:39 |
Anonymous (not verified) |
64.191.6.226 |
Wedeking Custom Comfort LLC |
Limited Liability Company |
17541 Ridge Ave Clarksville, IA 50619 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Justin Wedeking |
wedeking42@gmail.com |
Clarksville |
Butler |
Iowa |
Jason Grant |
Richard Grant |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Wedeking |
wedeking42@gmail.com |
Self |
Clarksville |
butler |
Iowa |
Jason Grant |
Richard Grant |
Signed |
1785 |
2023-08-06 17:37 |
Anonymous (not verified) |
94.188.207.225 |
J and B Zuck Trucking LLC |
Limited Liability Company |
7310 E Airline Hwy 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. |
2023-08-08 |
Justin Zuck |
jandbzucktrucking@gmail.com |
DUNKERTON |
Iowa |
United States |
Justin Zuck |
Rebekah Zuck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Zuck |
jandbzucktrucking@gmail.com |
owner |
DUNKERTON |
Iowa |
United States |
Justin Zuck |
Rebekah Zuck |
Signed |
402 |
2021-02-15 16:33 |
Anonymous (not verified) |
66.188.136.150 |
K.C. Ansel |
Proprietorship |
101 Cherokee Dr. 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. |
2021-02-15 |
K.C. Ansel |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
K.C. Ansel |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Shuree Behr |
Signed |
1748 |
2023-07-17 06:35 |
Anonymous (not verified) |
94.188.205.177 |
Westys paint and stain llc |
Limited Liability Company |
1961 150th st 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. |
2023-07-17 |
Kaitlin westendorf |
westyspaint@gmail.com |
Waverly |
Bremer |
Iowa |
Kathy westendorf |
Michael westendorf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Westys paint & stain llc |
westyspaint@gmail.com |
Owner |
Waverly |
Bremer |
Iowa |
Kathy westendorf |
Michael westendorf |
Signed |
1874 |
2023-10-22 11:54 |
Anonymous (not verified) |
94.188.205.166 |
Midwest UAV LLC |
Limited Liability Company |
1400 15th St SE Bondurant Iowa 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. |
2023-10-22 |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Owner |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
1476 |
2023-02-22 12:23 |
Anonymous (not verified) |
94.188.205.174 |
KARL INGWERSEN |
Proprietorship |
2716 FRANCIS SITES DR SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-22 |
KARL INGWERSEN |
KARL58INGWERSEN@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KARL INGWERSEN |
KARL58INGWERSEN@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKSINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1677 |
2023-06-02 11:37 |
Anonymous (not verified) |
94.188.207.230 |
Karl Klotzbach |
Proprietorship |
403 Jefferson, Decorah IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-02 |
Karl Klotzbach |
kdklotzbach@gmail.com |
Decorah |
Winneshiek |
Iowa |
Robin Schultz |
Jane Regan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Karl Klotzbach |
kdklotzbach@gmail.com |
Employer |
Decorah |
Winneshiek |
Iowa |
Robin Schutlz |
Jane M Regan |
Signed |
2047 |
2024-02-15 16:58 |
Anonymous (not verified) |
94.188.205.177 |
PorchLight Insights LLC |
Limited Liability Company |
2918 Campbell Street, Kansas City, MO 64109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-15 |
Kate Regnier Bender |
kate.bender@porchlightinsights.com |
Kansas City |
Jackson |
Missouri |
Jonathan Bender |
Brandon Steenson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kate Regnier Bender |
kate.bender@porchlightinsights.com |
Co-Founder |
Kansas City |
Jackson |
Missouri |
Jonathan Bender |
Brandon Steenson |
Signed |
787 |
2021-12-13 16:15 |
Anonymous (not verified) |
64.5.77.84 |
Heartland Counseling Services |
Limited Liability Company |
813 Flindt 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. |
2021-11-05 |
Kathleen Ruscitto |
info@heartlandcounselingia.com |
STORM LAKE |
Iowa |
United States |
David Kirk |
Michael Robertson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kathleen Ruscitto |
info@heartlandcounselingia.com |
Self/Owner |
STORM LAKE |
Iowa |
United States |
David Kirk |
Michael Robertson |
Signed |
139 |
2020-04-28 10:11 |
Anonymous (not verified) |
74.84.101.138 |
Nisse Preschool & Kids Place |
Partnership |
311 College Drive 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. |
2020-02-26 |
Kathleen Schutte |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kathleen Schutte |
chelsea.whalen@upperiowains.com |
Treasurer |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
2181 |
2024-04-25 15:41 |
Anonymous (not verified) |
94.188.205.168 |
Ev's Ice Cream LLC |
Limited Liability Company |
2205 1/2 S Center St, Marshalltown, IA 50158-5960 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Self |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
1136 |
2022-05-31 13:46 |
Anonymous (not verified) |
173.31.148.43 |
OKOBOJI BURRITO COMPANY LLC |
Limited Liability Company |
39502 710TH ST LAKEFIELD, MN 56105 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-26 |
KATHRYN SCHULTZ |
kathrynlucier@ymail.com |
LAKEFIELD |
JACKSON |
MN |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATHRYN SCHULTZ |
kathrynlucier@ymail.com |
SELF |
LAKEFIELD |
JACKSON |
MN |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
339 |
2020-12-15 15:23 |
Anonymous (not verified) |
74.221.46.229 |
CORRECTIONVILLE GOLF CLUB INC |
Limited Liability Company |
1300 HACKBERRY STREET CORRECTIONVILLE IA 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. |
2020-12-15 |
KATIE EDWARDS |
KEDWARDS@FNBCORRECTIONVILLE.COM |
CORRECTIONVILLE |
WOODBURY |
IA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KIM MEBIUS |
KMEBIUS@FNBCORRECTIONVILLE.COM |
PRESIDENT |
CORRECTIONVILLE |
WOODBURY |
IA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
1184 |
2022-07-06 15:10 |
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 |
Kaylee Goshorn |
shelbycountyfair@fmctc.com |
Harlan |
Shelby |
iowa |
Kate Heese |
Katie Petersen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kaylee Goshorn |
shelbycountyfair@fmctc.com |
Board Member |
Harlan |
Shelby |
Iowa |
Kate Heese |
Katie Petersen |
Signed |
1462 |
2023-02-17 13:45 |
Anonymous (not verified) |
94.188.207.227 |
Med Spa Institute of America, Dubuque LLC |
Limited Liability Partnership |
3337 Hillcrest Rd - Dubuque, IA 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-11 |
Kaylee Webb |
jheims@english-insurance.com |
Dubuque |
Dubuque |
United States |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
self |
Dyersville |
IA |
United States |
Joyce Heims |
Derrick Parsons |
Signed |
1758 |
2023-07-20 16:37 |
Anonymous (not verified) |
94.188.205.174 |
Nailed It Remodeling Services LLC |
Limited Liability Company |
1520 Burnett Ave Ames, IA 50010 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-20 |
Kaylyn Christianson |
kaylynchristianson@gmail.com |
Ames |
Story |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kaylyn Christianson |
KaylynChristianson@gmail.com |
Manager |
Ames |
Story |
Iowa |
Jon Buller |
Terry Miles |
Signed |
1942 |
2023-12-06 13:45 |
Anonymous (not verified) |
94.188.207.228 |
K&K Service |
Limited Liability Company |
6125 R57 Hwy Indianola, IA 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Keaton Klocko |
kklocko30@aim.com |
Indianola |
Warren |
Iowa |
Kourtne Klocko |
Mallory Metzger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keaton Klocko |
kklocko30@aim.com |
Owner |
Indianola |
Warren |
Iowa |
Kourtne Klocko |
Mallory Metzger |
Signed |
1381 |
2022-11-30 20:41 |
Anonymous (not verified) |
97.125.145.12 |
Central Iowa Outdoor Services |
Proprietorship |
1213 Parkhill 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. |
2022-11-30 |
Keegan Eggers |
CentralIowaServices1@gmail.com |
Norwalk |
Iowa |
United States |
Stephanie Eggers |
Kelsie Eggers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keegan Eggers |
CentralIowaServices1@gmail.com |
Owner |
Norwalk |
Iowa |
United States |
Stephanie Eggers |
Kelsie Eggers |
Signed |
1755 |
2023-07-19 22:43 |
Anonymous (not verified) |
94.188.207.230 |
Ellison building and repair |
Limited Liability Company |
2722 645th ave moravia iowa 52571 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Keeton Ellison |
sammyllsn@yahoo.com |
Moravia |
Appanoose |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sammy Ellison |
sammyllsn@yahoo.com |
Mom |
Moravia |
Monroe |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
1822 |
2023-08-29 11:52 |
Anonymous (not verified) |
94.188.207.224 |
Ellison building and repair |
Limited Liability Company |
2722 645th ave moravia iowa 52571 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-18 |
Keeton Ellison |
keeton2005@gmail.com |
Moravia |
Appanoose |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sammy Ellison |
sammyllsn@yahoo.com |
Mom |
Moravia |
Monroe |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
513 |
2021-05-11 13:14 |
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 |
KEITH CACEK |
KEITH@RUTHVENROCKS.COM |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEITH CACEK |
joel@walkerinsuranceia.com |
MEMBER |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1288 |
2022-08-30 16:23 |
Anonymous (not verified) |
50.83.35.94 |
Black Rock Flooring LLC |
Limited Liability Company |
189 9th st. 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. |
2022-08-30 |
Keith Douglas Luye Sr. |
Blackrockflooriing@gmail.com |
Marion |
Linn |
Iowa |
Cari Beth Lamb |
Daniel Ray Lamb |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith Douglas Luye Sr. |
Blackrockflooring@gmail.com |
self / my own authorized agent |
Marion |
Linn |
Iowa |
Cari Beth Lamb |
Daniel Ray Lamb |
Signed |
758 |
2021-11-19 15:12 |
Anonymous (not verified) |
184.80.177.137 |
Upper Room, LLC |
Limited Liability Company |
1314 9th St SE - 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. |
(1) I am not electing the employers’ liability coverage. |
2021-11-19 |
Keith 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 |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
279 |
2020-10-19 08:02 |
Anonymous (not verified) |
66.188.136.150 |
Keith McNair |
Proprietorship |
13436 Silver Brook Dr. Pickerington, OH 43147 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-16 |
Keith McNair |
kschumacher@tricorinsurance.com |
Pickerington |
Fairfield |
OH |
Nancy Wortley |
Russell Masartis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith McNair |
kschumacher@tricorinsurance.com |
Same |
Pickerington |
Fairfield |
OH |
Nancy Wortley |
Russell Masartis |
Signed |
1040 |
2022-04-12 09:36 |
Anonymous (not verified) |
173.31.148.43 |
PAPA'S SMOKIN MEAT |
Proprietorship |
1940 147TH ST 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. |
2022-04-12 |
KEITH MORISTON |
PAPASSMOKINMEAT@GMAIL.COM |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEITH MORISTON |
PAPASSMOKINMEAT@GMAIL.COM |
SELF |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
252 |
2020-09-09 10:38 |
Anonymous (not verified) |
65.103.82.36 |
KNS |
Proprietorship |
PO Box 2632 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-04 |
Keith N Slyter |
KNSCONST@gmail.com |
Davenport |
Scott |
Iowa |
Eric Johnson |
Dawn Tague |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith N Slyter |
knsconst@gmail.com |
self |
Davenport |
Scott |
Ia |
Dawn Tague |
Eric Johnson |
Signed |
84 |
2020-02-28 15:30 |
Anonymous (not verified) |
198.167.182.164 |
Rid-A-Bird Inc. |
Limited Liability Company |
3116 Friendship St. Iowa City IA 52245 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-28 |
Keith Wilson |
kwilson@windowgenie.com |
Iowa City |
Johnson |
Iowa |
Dyan Kriener |
Marcia A Colvin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith Wilson |
kwilson@windowgenie.com |
Managing member |
Iowa City |
Johnson |
Iowa |
Dyan Kriener |
Marcia A Colvin |
Signed |
1121 |
2022-05-19 17:45 |
Anonymous (not verified) |
107.115.239.35 |
KG Land works LLC |
Limited Liability Company |
P.O. Box 931Barnsdall Oklahoma 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-19 |
Keiven Brooke Slone |
keiven.slone@gmail.com |
Barnsdalll |
Osage |
OK |
Colton Kelley |
Dalton Gardner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Owner |
Barnsdalll |
Osage |
OK |
Dalton Garder |
Jacob Kelley |
Signed |
1248 |
2022-08-09 11:29 |
Anonymous (not verified) |
166.181.82.131 |
Kelly Kellogg |
Proprietorship |
1305 N 1st st apt 16 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-09 |
Kelly |
Kkell0223@gmail.com |
Indianola |
Warren |
Iowa |
Kelly Kellogg |
Amy Kellogg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Royal flooring |
workorders@shoproyalflooring.com |
Employee |
Urbandale |
Polk |
Iowa |
Amy |
Kelly |
Signed |
1249 |
2022-08-09 14:14 |
Anonymous (not verified) |
166.181.82.131 |
Kelly Kellogg |
Proprietorship |
1305 N 1st st apt 16 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-09 |
Kelly Kellogg |
Kkell0223@gmail.com |
Indianola |
Warren |
Iowa |
Kelly Kellogg |
Amy Kellogg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kelly's Flooring |
Kkell0223@gmail.com |
Myself |
1305 N 1st st apt 16 |
Warren |
Iowa |
Kelly Kellogg |
Amy Kellogg |
Signed |
715 |
2021-11-05 11:27 |
Anonymous (not verified) |
209.252.172.87 |
Ken Clifford |
Proprietorship |
132121st Ave SW Cedar Rapids, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-18 |
Ken Clifford |
ken40406108@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ken Clifford |
ken40406108@gmail.com |
Self Employer |
Cedar Rapids |
Linn |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
2146 |
2024-04-12 11:42 |
Anonymous (not verified) |
94.188.207.226 |
Ken McGraw |
Proprietorship |
162 Green St Center Point IA 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. |
2024-04-12 |
Ken Mcgraw |
kenmcgraw1974@gmail.com |
Center Point |
Linn |
Iowa |
Jenny Vaske |
Bob Nissen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Cedar Rapids |
Linn |
Iowa |
Bob Nissen |
Jenny Vaske |
Signed |
2147 |
2024-04-12 11:52 |
Anonymous (not verified) |
94.188.205.166 |
Tri County Enterprise |
Partnership |
5527 Crane Lane 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. |
2024-04-12 |
Ken McGraw |
kenmcgraw1974@gmail.com |
Center Point |
IA |
United States |
bob nissen |
Jenny Vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Shellsburg |
IA |
United States |
bob Nissen |
Jenny Vaske |
Signed |
845 |
2022-01-20 09:06 |
Anonymous (not verified) |
208.126.69.10 |
KenX Pest Control |
Limited Liability Company |
350 2nd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-20 |
Ken YARRINGTON |
kenxpestcontrol@hotmail.com |
Truro |
IA |
IA |
James Gage |
Kent Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kenneth Charles Yarrington |
kenxpestcontrol@hotmal.com |
Myself |
Truro |
IA |
IA |
James Gage |
Kent Smith |
Signed |
177 |
2020-06-08 11:00 |
Anonymous (not verified) |
173.28.28.57 |
Lakeview Retreat Center, LLC |
Limited Liability Company |
17726 260th 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. |
2020-05-23 |
Kendale Winkowitsch |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kendale Winkowitsch |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
773 |
2021-11-24 14:48 |
Anonymous (not verified) |
24.149.18.237 |
The Ragged Edge Art Bar and Gallery |
Limited Liability Company |
504 Bluff 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. |
2021-11-24 |
Kendra Wohlert |
kwohlert43@gmail.com |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kendra Wohlert |
kwohlert43@gmail.com |
self |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
797 |
2021-12-15 08:01 |
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 |
Kenneth Roman 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 |
535 |
2021-06-04 13:16 |
Anonymous (not verified) |
192.119.129.187 |
KMA Communications, LLC |
Limited Liability Company |
435 croston rd. Stockport, OH 43787 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-04 |
Kenneth Stephen Alsup |
kenneth.alsup@yahoo.com |
Walker |
Wood |
West Virginia |
Stephen Alsup |
Nancy Alsup |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kenneth Stephen Alsup |
kenneth.alsup@yahoo.com |
Same Person |
Walker |
Wood |
West Virginia |
Stephen Alsup |
Nancy Alsup |
Signed |
817 |
2021-12-30 12:58 |
Anonymous (not verified) |
50.80.80.37 |
Leaf Filter |
Limited Liability Company |
1595 Georgetown Road 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. |
2021-12-30 |
Kenneth Van Hook |
kennyvanhook1976@gmail.com |
Port Byron |
Rock Island |
IL |
Sharon Van Hook |
Judy Hoffman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Dunbar |
cdunbar@leaffilter.com |
Manager |
Bettendorf |
Scott County |
IA |
Cody Dunbar |
Jordan Nisiewicz |
Signed |
1575 |
2023-04-16 09:00 |
Anonymous (not verified) |
94.188.205.176 |
Velocity Improvement, LLC |
Proprietorship |
PO Box 903, Wilton IA 52778 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-16 |
Kent Grunhovd |
velocityimprovement@gmail.com |
Wilton |
Scott |
Iowa |
Robin Throne |
LaVonne Grunhovd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kent Grunhovd |
kgrunhovd3535@gmail.com |
Self |
Bloomington |
McLean |
IL |
Robin Throne |
LaVonne Grunhovd |
Signed |
228 |
2020-08-07 13:49 |
Anonymous (not verified) |
173.28.28.57 |
Coffee Grounds, LLC dba Bev & Hennie's |
Limited Liability Company |
604 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. |
2020-07-28 |
Kent Klooster |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kent Klooster |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
2095 |
2024-03-14 11:39 |
Anonymous (not verified) |
205.221.255.62 |
Trimble Lawncare And Landscaping |
Proprietorship |
215 Boundary Ave Middletown IA 52638 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-14 |
Kevin Blake Trimble |
rknhtrimble@yahoo.com |
Middletown |
Des Moines |
Iowa |
Katelyn Orth |
Shayla Taeger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Blake Trimble |
rknhtrimble@yahoo.com |
owner |
Middletown |
Des Moines |
Iowa |
Katelyn Orth |
Shayla Taeger |
Signed |
2006 |
2024-01-29 11:04 |
Anonymous (not verified) |
94.188.207.224 |
Kevin Jones |
Proprietorship |
1500 15Th St. Milford IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-29 |
KEVIN JONES |
KEVINMJONES81@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JOSEPH LORING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEVIN JONES |
KEVINMJONES81@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JOSEPH LORING |
Signed |
1675 |
2023-06-02 09:37 |
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 |
Kevin 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% Owner - President |
Vinton |
Benton |
Iowa |
Ashlyn J. Christianson |
Angie McFarland |
Signed |
166 |
2020-05-27 11:48 |
Anonymous (not verified) |
66.188.136.150 |
Kevin Kerstetter |
Proprietorship |
1080 E 12th St. 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. |
2020-05-26 |
Kevin Kerstetter |
kschumacher@tricorinsurance.com |
Cuyahoga Falls |
Summit County |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Kerstetter |
kschumacher@tricorinsurance.com |
Same |
Cuyahoga Falls |
Summit County |
OH |
Russell Masartis |
Nancy Wortley |
Signed |
863 |
2022-01-27 12:13 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction llc |
Limited Liability Company |
4508 Hiawatha 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. |
2022-01-27 |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Allen Becker |
mike4bbc@gmail.com |
Brother/Partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
1242 |
2022-08-03 14:53 |
Anonymous (not verified) |
107.141.197.247 |
Hygieia Stainless Solutions LLC |
Limited Liability Company |
2200 Blairsferry Crossing Hiawatha, IA 52233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-03 |
Kevin R Dibel |
kevin.dibel@hygieiastainless.com |
Lebanon |
Wilson |
Tennessee |
Andy Scanlon |
Roger Batterson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Kevin R Dibel |
kevin.dibel@hygieiastainless.com |
self |
Lebanon |
Wilson |
Tennessee |
Andy Scanlon |
Roger Batterson |
Signed |
1296 |
2022-09-07 08:55 |
Anonymous (not verified) |
67.55.155.204 |
Kevin Utterback II |
Proprietorship |
801 E Ave W. Oskaloosa, Iowa 52577 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Kevin Utterback II |
mark@johnsoninsurancesales.com |
Oskaloosa |
Iowa |
Iowa |
Scott Miller |
Kim Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Utterback |
mark@johnsoninsurancesales.com |
owner of company |
Oskaloosa |
Iowa |
Iowa |
Scott Miller |
Kim Miller |
Signed |
1374 |
2022-11-17 14:33 |
Anonymous (not verified) |
72.106.129.202 |
Cowman Consulting and Construction LLC |
Limited Liability Company |
740 NE Horizon Dr, Waukee IA 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-17 |
Khalid Cowman |
khalidcowman1@gmail.com |
Waukee |
Dalls |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Khalid Cowman |
khalidcowman1@gmail.com |
Self/Owner |
Waukee |
Dallas |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
706 |
2021-11-02 11:45 |
Anonymous (not verified) |
50.82.130.211 |
Kierstyn Anest |
Proprietorship |
1200 Parriott Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-25 |
Kierstyn Anest |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kerstyn Anest |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1198 |
2022-07-11 15:46 |
Anonymous (not verified) |
74.84.91.178 |
Dave's Remodeling LLC |
Limited Liability Company |
2308 Long Grove Ct, Dubuque, IA 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Kim Kern |
davesremodeling@aol.com |
Asbury |
Dubuque |
Iowa |
Brenda Lewis |
Gabe Drewlow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kim Kern |
davesremodeling@aol.com |
co-owner |
Asbury |
Dubuque |
Iowa |
Brenda Lewis |
Gabe Drewlow |
Signed |
813 |
2021-12-27 10:18 |
Anonymous (not verified) |
172.58.84.252 |
LLC |
Partnership |
866 40th Ave Bettendorf, 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. |
2021-12-23 |
Kimberly Anne Liggitt |
kliggitt25@gmail.com |
Rock Island |
IL |
United States |
Suzanne Jeanette Liggitt |
Christie Marie Liggitt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Dunbar |
codydunbar@leaffilter.com |
Manager |
866 40th Ave Bettendorf ia 52722 |
Scott County |
IA |
Jordan nisiewicz |
Cody Dunbar |
Signed |
909 |
2022-02-10 08:03 |
Anonymous (not verified) |
166.181.83.242 |
Kim Hildebrand |
Proprietorship |
130 Sabrina cir Waterloo, IA 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-07 |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Self |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
1164 |
2022-06-23 09:26 |
Anonymous (not verified) |
74.84.106.106 |
Kimberly Owens |
Proprietorship |
2503 E 23rd street Newton, IA 50228 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-23 |
Kimberly Owens |
kimmybobby1220@gmail.com |
Newton |
Jasper |
Iowa |
Rita Littrell |
Tina Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Owens |
kimmybobby1220@gmail.com |
Self |
Newton |
Jasper |
Iowa |
Rita Littrell |
Tina Owens |
Signed |
2009 |
2024-01-29 22:59 |
Anonymous (not verified) |
94.188.207.226 |
Kimberly Ruby Reyes Victoriano |
Proprietorship |
1910 Eric 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. |
2024-01-29 |
Kimberly Ruby Reyes Victoriano |
InOnePieceDrywall@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Juan Jose Victoriano Ramirez |
Denir Billy Flores |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Ruby Reyes Victoriano |
InOnePieceDrywall@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Juan Jose Victoriano Ramirez |
Fredy Perez Perez |
Signed |
1634 |
2023-05-10 07:21 |
Anonymous (not verified) |
94.188.205.174 |
KS Drywall |
Proprietorship |
404 E Jayne Street Lone Tree, IA 52755 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Kirk Strunk |
kirkstrunk@gmail.com |
Lone Tree |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kirk Strunk |
kirkstrunk@gmail.com |
Self |
Lone Tree |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
1678 |
2023-06-06 08:13 |
Anonymous (not verified) |
94.188.205.168 |
Castor Construction |
Limited Liability Company |
1515 Avenue O Fort Dodge, Iowa 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. |
2023-06-06 |
Kit Hovey |
hoveykit@gmail.com |
FORT DODGE |
Webster |
United States |
Alexis Malm |
Kit Hovey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Noah Carspecken |
noah@castorconstructionco.com |
Management |
FORT DODGE |
Webster |
United States |
Alexis Malm |
Kit Hovey |
Signed |
378 |
2021-01-29 11:43 |
Anonymous (not verified) |
50.82.21.136 |
GRAPHIX MASTERS |
Limited Liability Company |
420 Hamilton St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-01-29 |
Klayton Karl Kirkpatrick |
klay@graphixmasters.us |
Ottumwa |
IA |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Klayton Kirkpatrick |
klay@graphixmasters.us |
Same |
Ottumwa |
Iowa |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |
1913 |
2023-11-20 13:48 |
Anonymous (not verified) |
94.188.205.167 |
KWF SALES INC |
Proprietorship |
216 WINDFLOWER 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. |
2023-11-20 |
KRISTI A WOODLEY-FLANSBURG |
Kwflansburg@gmail.com |
SOLON |
Iowa |
Iowa |
ZACH GRANT |
TOM SIMPSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KRISTI A WOODLEY-FLANSBURG |
Kwflansburg@gmail.com |
SELF |
SOLON |
IA |
IA |
ZACH GRANT |
TOM SIMPSON |
Signed |
1876 |
2023-10-23 14:26 |
Anonymous (not verified) |
94.188.205.169 |
Magnus, LLC |
Limited Liability Company |
1120 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. |
2023-10-23 |
Kristina Link |
magnina@aol.com |
Cedar Rapids |
IA |
IA |
Shannon Thompson |
Jeff Spies |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristina Link |
magnina@aol.com |
business owner |
Cedar Rapids |
Iowa |
Iowa |
Shannon Thompson |
Jeff Spies |
Signed |
906 |
2022-02-09 08:57 |
Anonymous (not verified) |
173.28.0.37 |
CAB Holdings LLC |
Limited Liability Company |
804 SE Cherry 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. |
2022-02-09 |
Kristy Briles |
kristyabriles@gmail.com |
Des Moines |
Polk |
IA |
Stephanie Seymour |
Sue Briles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristy Briles |
kristyabriles@gmail.com |
owner |
Des Moines |
Polk |
IOwa |
Stephanie Seymour |
Sue Briles |
Signed |
907 |
2022-02-09 08:59 |
Anonymous (not verified) |
173.28.0.37 |
Rusty K5 LLC |
Limited Liability Company |
804 SW Cherry 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. |
2022-02-09 |
Kristy Briles |
kristyabriles@gmail.com |
Des Moines |
Polk |
IA |
Stephanie Seymour |
Sue Briles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristy Briles |
kristyabriles@gmail.com |
Owner |
Des moines |
Polk |
IA |
50313 |
Sue Briles |
Signed |
1074 |
2022-04-27 12:16 |
Anonymous (not verified) |
66.129.216.227 |
Kristyn M Gerst Counseling LLC |
Limited Liability Company |
30 Villager Dr. Apt. 3 North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-27 |
Kristyn May Gerst |
kmwatson18@gmail.com |
North Liberty |
johnson |
Iowa |
Forrest John Gerst |
Heather Lynn Watson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristyn May Gerst |
kmwatson18@gmail.com |
self |
North Liberty |
Johnson |
Iowa |
Forrest John Gerst |
Heather Lynn Watson |
Signed |
2212 |
2024-05-08 13:26 |
Anonymous (not verified) |
94.188.207.224 |
Lifetime Roofing Installations, LLC |
Limited Liability Company |
703 2nd St. SW 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. |
2024-05-08 |
Kurtis Walvatne |
lifetimeroofing12@yahoo.com |
Tripoli |
Bremer |
Iowa |
Mike Meyer |
Kelly Walvatne |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kurtis Walvatne |
lifetimeroofing12@yahoo.com |
Owner |
Tripoli |
Bremer |
Iowa |
Mike Meyer |
Kelly Walvatne |
Signed |
831 |
2022-01-12 15:10 |
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. |
2022-01-12 |
Kyle Alan Schultz |
schultzkyle01@gmail.com |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Erica Schultz |
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 |
Erica Schultz |
Signed |
1674 |
2023-06-02 09:34 |
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 |
Kyle 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 |
1187 |
2022-07-06 15:51 |
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 |
Kyle Manz |
shelbycountyfair@fmctc.com |
Harlan |
Shelby |
Iowa |
Kate Heese |
Katie Petersen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Manz |
shelbycountyfair@fmctc.com |
Board Member |
Harlan |
Shelby |
Iowa |
Kate Heese |
Katie Petersen |
Signed |
1885 |
2023-10-29 08:05 |
Anonymous (not verified) |
94.188.207.223 |
MB Radon Services |
Limited Liability Company |
13206 State Hwy 2, Lamoni, Iowa, 50140 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-29 |
Kyle Ramaeker |
raymaker83@gmail.com |
LAMONI |
IA |
United States |
Adam Boge |
Lance Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Ramaeker |
raymaker83@gmail.com |
Owner/Operator |
LAMONI |
IA |
United States |
Adam Boge |
Lance Webster |
Signed |
1263 |
2022-08-16 13:18 |
Anonymous (not verified) |
70.96.153.153 |
Sinnott Solutions LLC |
Limited Liability Company |
1798 643rd Ln, 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. |
2022-08-16 |
Kyle Sinnott |
kyle.s@optionsexteriors.com |
Albia |
Monroe County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Sinnott |
kyle.s@optionsexteriors.com |
Owner/Self |
Albia |
Monroe |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
1459 |
2023-02-16 09:07 |
Anonymous (not verified) |
94.188.205.166 |
Lakerats |
Limited Liability Company |
112 W Court 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. |
2023-02-05 |
Kyra Moore |
kyra@novushomemortgage.com |
Urbandale |
Polk |
Iowa |
Jessica Anderson |
Easton Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyra Moore |
kyra@novushomemortgage.com |
Owner |
Urbandale |
Polk |
Iowa |
Jessica Anderson |
Easton Anderson |
Signed |
149 |
2020-05-06 08:33 |
Anonymous (not verified) |
66.188.136.150 |
Lacey Doyle |
Proprietorship |
210 Austin Ct. Apt 10 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. |
2020-05-05 |
Lacey Doyle |
kschumacher@tricorinsurance.com |
Epworth |
Dubuque |
IA |
Russell Masartis |
Rose Horstman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lacey Doyle |
kschumacher@tricorinsurance.com |
Same |
Epworth |
Dubuque |
IA |
Russell Masartis |
Rose Horstman |
Signed |
168 |
2020-05-28 11:29 |
Anonymous (not verified) |
173.31.147.225 |
RECYCLED SPIRITS LLC |
Limited Liability Company |
43 ANN STREET 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 |
LACEY LAAKE |
BLAMB@SPENCERSCHOOLS.ORG |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LACEY LAAKE |
BLAMB@SPENCERSCHOOLS.ORG |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
1742 |
2023-07-12 12:43 |
Anonymous (not verified) |
94.188.207.228 |
Old Glory Home Improvements LLC |
Limited Liability Company |
117 E Church st, Panora, 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. |
2023-07-12 |
Laden Binjiman McDonald |
mcdonaldladen@gmail.com |
Waukee |
Dallas |
Iowa |
Tina McDonald |
Matt McDonald |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Northwest Registered Agent |
bmartin@frannet.com |
Employer |
Panora |
Guthrie |
Iowa |
Tina McDonald |
Matt McDonald |
Signed |
1431 |
2023-01-25 16:24 |
Anonymous (not verified) |
172.56.249.51 |
Warren transport |
Limited Liability Company |
3124 titan trail Waterloo,iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-25 |
Lamarcaus Lunford |
universalvoyager1@gmail.com |
Elkhart |
IN |
Indiana |
Quinetta shead |
Eric fikes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lamarcaus Lunford |
universalvoyager1@gmail.com |
Owner |
Elkhart |
IN |
Indiana |
Quinetta shead |
Eric fikes |
Signed |
82 |
2020-02-25 17:32 |
Anonymous (not verified) |
66.43.239.175 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-25 |
Lance Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Dena M. Anderson |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
lanceandabby@wccta.net |
Officer |
Churdan |
Greene |
IA |
Dena M Anderson |
Shelly Brus |
Signed |
971 |
2022-03-14 17:59 |
Anonymous (not verified) |
207.32.37.48 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan, IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Lance Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
accounting@lynxag.com |
Officer |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
417 |
2021-03-03 13:49 |
Anonymous (not verified) |
173.215.42.12 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-03 |
Lance Jeffrey Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Shelly L. Brus |
Dena M. Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
accounting@lynxag.com |
Officer |
Churdan |
Greene |
Iowa |
Shelly L. Brus |
Dena M. Anderson |
Signed |
1548 |
2023-03-30 14:18 |
Anonymous (not verified) |
94.188.207.229 |
Lance Jordison |
Proprietorship |
2295 Nelson Ave, 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. |
2023-03-30 |
Lance Jordison |
jordisontrucking@gmail.com |
Fort Dodge |
Webster |
Iowa |
Ashlee Neumann |
Ed Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Jordison |
jordisontrucking@gmail.com |
Owner |
Fort Dodge |
Webster |
Iowa |
Ashlee Neumann |
Ed Smith |
Signed |
1580 |
2023-04-17 20:22 |
Anonymous (not verified) |
94.188.205.167 |
Lance Van Der weerd |
Limited Liability Company |
909 S Adams Street 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. |
2023-04-17 |
Lance Van Der Weerd |
enterprisesvdw@gmail.com |
Rock Rapids |
IA |
United States |
Brittany Van Der Weerd |
Todd Mienerts |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Van Der Weerd |
enterprisesvdw@gmail.com |
Myself |
Rock Rapids |
Lyon |
Iowa |
Brittany Van Der Weerd |
Todd Mienerts |
Signed |
1241 |
2022-08-03 10:56 |
Anonymous (not verified) |
72.169.80.108 |
Landon Henriksen |
Proprietorship |
35374 GARDEN 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-03 |
LANDON HENRIKSEN |
HENRIKSENLK@AOL.COM |
Edgewood |
IA |
United States |
LANDON HENRIKSEN |
LANDON HENRIKSEN |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
LANDON HENRIKSEN |
HENRIKSENLK@AOL.COM |
Same |
Edgewood |
IA |
United States |
Scott Johnson |
Josh lafond |
Signed |
1427 |
2023-01-23 10:53 |
Anonymous (not verified) |
174.198.74.123 |
Landon Manfull |
Proprietorship |
51909 hwy 210 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Landon Manfull |
landonmanfull1@gmail.com |
Slater |
Story |
Iowa |
Landon Manfull |
Landon Manfull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Landon Manfull |
landonmanfull1@gmail.com |
Myself |
Slater |
Story |
Iowa |
Landon Manfull |
Landon Manfull |
Signed |
1488 |
2023-02-28 14:04 |
Anonymous (not verified) |
94.188.207.227 |
Scotts Side Work Plus |
Limited Liability Company |
304 Wilshire Blvd 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. |
2023-02-28 |
Lansing Scott |
scottssideworkplus@gmail.com |
Windsor Heights |
Iowa |
United States |
Collin scott |
Austyn Scott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lansing Scott |
scottssideworkplus@gmail.com |
owner |
Windsor Heights |
Iowa |
United States |
Austyn Scott |
Tracy scott |
Signed |
148 |
2020-05-04 15:49 |
Anonymous (not verified) |
173.28.28.57 |
LaRae Randall dba Wild Soul Photo |
Proprietorship |
19019 O Avenue, Grundy Center, IA 50638 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
LaRae Randall |
cmins_re@mchsi.com |
Grundy Center |
Grundy |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LaRae Randall |
cmins_re@mchsi.com |
Self |
Grundy Center |
Grundy |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
1728 |
2023-07-08 10:48 |
Anonymous (not verified) |
94.188.207.230 |
Lima Charlie LLC |
Limited Liability Company |
56066 257th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-10 |
Larry Homan |
larry@Lima-Charlie.biz |
Glenwood |
Iowa |
United States |
Erin Jenkins |
Jeremy Jenkins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Larry Lee Homan |
Larry@Lima-Charlie.biz |
Owner |
Glenwood |
Iowa |
United States |
Erin Homan |
Jeremy Jenkins |
Signed |
1759 |
2023-07-26 07:09 |
Anonymous (not verified) |
94.188.207.225 |
Lima Charlie LLC |
Limited Liability Company |
56066 257th Street, Glenwood, IA 51534 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-26 |
Larry Joshua Homan |
Joshua@Lima-Charlie.biz |
Flatonia |
TX |
United States |
Leisha Kolb |
Troy Kolb |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Larry Joshua Homan |
Joshua@lima-charlie.biz |
Owner |
Flatonia |
Texas |
United States |
Leisha Kolb |
Troy Kolb |
Signed |
671 |
2021-10-13 15:00 |
Anonymous (not verified) |
173.23.180.179 |
Larry and Company Inc. |
Proprietorship |
7239 Osage Road, 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. |
2021-10-13 |
Larry Rust |
larryandcoinc@hotmail.com |
Waterloo |
Black Hawk |
Iowa |
Lisa Kay Buls |
Kevin Thomas Buls |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Larry Alan Rust |
larryandcoinc@hotmail.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Lisa Kay Buls |
Kevin Thomas Buls |
Signed |
2085 |
2024-03-08 15:22 |
Anonymous (not verified) |
94.188.207.227 |
Laura Cook |
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 |
Laura Cook |
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 |
1331 |
2022-10-11 13:17 |
Anonymous (not verified) |
174.216.2.52 |
Parceros Construction LLC |
Limited Liability Company |
2315 Landon Rd. Apt. 206 North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-11 |
Laura Garavito |
ldanielagaravitog@gmail.com |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura Garavito |
ldanielagaravitog@gmail.com |
Owner |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
1343 |
2022-10-25 11:25 |
Anonymous (not verified) |
97.125.43.203 |
Midwest Pro Construction LLC |
Limited Liability Company |
1000 SE 11th St Apt 3202 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Laura Garcia |
deb@piciowa.com |
Grimes |
polk |
Iowa |
Debra Stratton |
Kenneth Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura Garcia |
deb@piciowa.com |
self |
Grimes |
Polk |
Iowa |
Debra Stratton |
Kenneth Stratton |
Signed |
1073 |
2022-04-27 08:44 |
Anonymous (not verified) |
173.187.173.190 |
black squirrel siding llc |
Limited Liability Company |
1512 North first ave apartment C203S Coralville, Iowa 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. |
2022-04-27 |
Lawerance James Brockert |
ozzman52382007@yahoo.com |
Atalissa |
Muscatine |
Iowa |
Rob Bartosh |
Jesse Minor-Nidey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lawerance James Brockert |
ozzman523582007@yahoo.com |
self |
Atalissa |
Muscatine |
Iowa |
Rob Bartosh |
Jesse Minor-Nidey |
Signed |
548 |
2021-06-24 22:08 |
Anonymous (not verified) |
173.31.28.69 |
Brown's Window Cleaning +PLUS |
Proprietorship |
700 11th 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. |
2021-06-24 |
Lawrence Brown |
brownswindowcleaningplus@gmail.com |
Altoona |
Iowa |
United States |
Jason Alderman |
Colette Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lawrence Brown |
brownswindowcleaningplus@gmail.com |
Self |
Altoona |
Iowa |
United States |
Jason Alderman |
Colette Evans |
Signed |
517 |
2021-05-12 15:08 |
Anonymous (not verified) |
66.188.136.150 |
Lawrence D Todd Jr. |
Proprietorship |
540 Sullivan St. 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. |
2021-05-05 |
Lawrence D Todd Jr. |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lawrence D Todd Jr. |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Shuree Behr |
Jordan Bass |
Signed |
95 |
2020-03-18 14:47 |
Anonymous (not verified) |
173.24.186.251 |
Layton C. Vick II dba Layton's Backhoe Service |
Proprietorship |
PO Box 652 / Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-18 |
Layton Clarence VIck II |
lcvii2@gmail.com |
Lake Park |
Dickinson |
Iowa |
Daniel Reimers |
Marcus VanKleek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Layton C. Vick II |
lcvii2@gmail.com |
Owner |
Lake Park |
Dickinson |
Iowa |
Daniel Reimers |
Marcus VanKleek |
Signed |
740 |
2021-11-11 14:54 |
Anonymous (not verified) |
72.13.16.172 |
LECHTENBERG TRUCKING LLC |
Limited Liability Company |
10185 HWY 18 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
LECHTENBERG TRUCKING LLC |
dave@allseasonstrucking.com |
POSTVILLE |
CLAYTON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LECHTENBERG TRUCKING LLC |
dave@allseasonstrucking.com |
PRESIDENT |
POSTVILLE |
CLAYTON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
1706 |
2023-06-23 17:32 |
Anonymous (not verified) |
94.188.205.169 |
pro plumbing and heating llc |
Limited Liability Company |
109 w market st, po box 205 saint charles ia 50240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
lee douglas kearney |
ankenypro@gmail.com |
saint charles |
madison |
iowa |
sheila may kearney |
madison grace kearney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
lee d kearney |
ankenypro@gmail.com |
owner |
saint charles |
madison |
iowa |
sheila may kearney |
madison grace kearney |
Signed |
1186 |
2022-07-06 15:49 |
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 |
Lee Schoof |
shelbycountyfair@fmctc.com |
Harlan |
Shelby |
Iowa |
Kate Heese |
Katie Petersen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lee Schoof |
shelbycountyfair@fmctc.com |
Board Member |
harlan |
Shelby |
Iowa |
Kate Heese |
Katie Petersen |
Signed |
1757 |
2023-07-20 14:45 |
Anonymous (not verified) |
94.188.207.230 |
Lee Steffen |
Proprietorship |
608 3rd Street NE, 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. |
2023-07-20 |
Lee Steffen |
lee.steffen22@icloud.com |
Farley |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lee Steffen |
lee.steffen22@icloud.com |
Self |
Farley |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
424 |
2021-03-05 15:56 |
Anonymous (not verified) |
65.103.82.36 |
Guardian Angel Specialty Cleaners |
Proprietorship |
1018 W 14th Street, 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. |
2020-06-18 |
Leesa Monson |
LMonson@gmail.com |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leesa Monson |
LMonson@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
1592 |
2023-04-22 22:46 |
Anonymous (not verified) |
94.188.207.223 |
D&L painting LLC |
Limited Liability Company |
3109 E13th 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. |
2023-04-22 |
Lenin Borjas Varela |
leninborjas92@gmail.com |
Des moines |
Iowa |
Iowa |
Berenice Silva |
Gustado Valdes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lenin Borjas Varela |
leninborjas92@gmail.com |
Dueño |
Clive |
Iowa |
Iowa |
Berenice silva |
Gustado Valdes |
Signed |
1131 |
2022-05-26 15:31 |
Anonymous (not verified) |
173.215.7.226 |
Leon's Construction |
Limited Liability Company |
524 CHURCH CIRCLE 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. |
2022-05-26 |
Leon Francis Delagardelle |
ldel1191961@hotmail.com |
JESUP |
Iowa |
Iowa |
Leon Francis Delagardelle |
Leon Francis Delagardelle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leon Francis Delagardelle |
ldel1191961@hotmail.com |
self |
JESUP |
Iowa |
Iowa |
Leon Francis Delagardelle |
Leon Francis Delagardelle |
Signed |
1518 |
2023-03-15 10:53 |
Anonymous (not verified) |
94.188.205.176 |
Leon's Construction |
Limited Liability Company |
524 CHURCH CIRCLE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-15 |
Leon Francis Delagardelle |
ldel1191961@hotmail.com |
JESUP |
Iowa |
United States |
Leon Francis Delagardelle |
Leon Francis Delagardelle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leon Francis Delagardelle |
ldel1191961@hotmail.com |
self |
JESUP |
Iowa |
United States |
Leon Francis Delagardelle |
Leon Francis Delagardelle |
Signed |
2065 |
2024-02-29 13:53 |
Anonymous (not verified) |
94.188.205.166 |
LEONARD BOUGHTON |
Partnership |
1616 AGENCY ST, BURLINGTON, IOWA 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. |
2024-02-29 |
LEONARD L BOUGHTON |
firstrate96@yahoo.com |
BURLINGTON |
DES MOINES |
IOWA |
PAM ZIPPE |
DEB SCOTT |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LEONARD L BOUGHTON |
firstrate96@yahoo.com |
Owner |
BURLINGTON |
DES MOINES |
IOWA |
PAM ZIPPE |
DEB SCOTT |
Signed |
1565 |
2023-04-11 09:49 |
Anonymous (not verified) |
94.188.205.177 |
Leonard Moss Roofing |
Proprietorship |
2018 Superior Street, Webster City, Iowa 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. |
2023-04-11 |
Leonard Moss |
leonard.moss48@gmail.com |
Webster City |
Hamilton |
Iowa |
Vicky Hahne |
Morgan Jensen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leonard Moss |
leonard.moss48@gmail.com |
Same |
Webster City |
Hamilton |
Iowa |
Vicky Hahne |
Morgan Jensen |
Signed |
1809 |
2023-08-21 07:55 |
Anonymous (not verified) |
94.188.207.228 |
Gonzalez Drywall LLC |
Limited Liability Company |
323 Friendhip St Apt 3, 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. |
2023-08-21 |
Leonel Angel Gonzalez |
victorangel8373@gmail.com |
Iowa City |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leonel Angel Gonzalez |
victorangel8373@gmail.com |
Self |
Iowa City |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
1645 |
2023-05-12 14:48 |
Anonymous (not verified) |
94.188.207.225 |
VL Drywall LLC |
Limited Liability Company |
1608 6th Ave SE Cedar Rapids |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
LESLIE LEYVA |
lleyva9696@gmail.com |
Cedar Rapids |
LINN |
Iowa |
Brad Bower |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leslie Leyva |
lleyva9696@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Chris Hay |
Brad Bower |
Signed |
1017 |
2022-03-29 14:53 |
Anonymous (not verified) |
208.81.192.69 |
Wapsie Valley Insulation, LLC |
Limited Liability Company |
1180 110th Street 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. |
2022-03-29 |
Lester Kauffman |
bookkeeping@robertseddy.com |
Fairbank |
Buchanan |
Iowa |
Sarah Van Buren |
Julie Ohl |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lester Kauffman |
bookeeping@robertseddy.com |
Same |
Fairbank |
Buchanan |
Iowa |
Sarah Van Buren |
Julie Ohl |
Signed |
1756 |
2023-07-20 11:19 |
Anonymous (not verified) |
94.188.205.169 |
LEVI GONZALEZ |
Proprietorship |
2212 OKOBOJI 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. |
2023-07-13 |
LEVI GONZALEZ |
joel@walkerinsuranceia.com |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LEVI GONZALEZ |
JOEL@WALKERINSURANCEIA.COM |
SELF |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI KLEIN |
Signed |
1773 |
2023-08-03 08:24 |
Anonymous (not verified) |
94.188.207.226 |
LR Construction LLC |
Limited Liability Company |
1564 110th 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. |
2023-07-23 |
Levi R Raber |
leviraber@amish.com |
Hazleton |
Buchanan |
Iowa |
Mary Ann Reber |
Daniel Raber |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Levi R Raber |
leviraber@amish.com |
self |
Hazleton |
Buchanan |
Iowa |
Julie Schick |
Kelly Matt |
Signed |
1840 |
2023-09-14 13:48 |
Anonymous (not verified) |
94.188.207.228 |
L.R. Construction, LLC |
Limited Liability Company |
1564 110th 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. |
2023-02-23 |
Levi R Raber |
amish@amish.com |
Hazleton |
Buchanan |
Iowa |
Mary Ann Raber |
Daniel Raber |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Levi R Raber |
amish@amish.com |
self |
Hazleton |
BUCHANAN |
Iowa |
Mary Ann Raber |
Daniel Raber |
Signed |
821 |
2022-01-04 10:06 |
Anonymous (not verified) |
173.18.4.60 |
Levi Walker |
Proprietorship |
601 N 10th Avenue Winterset, Iowa 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. |
2022-01-04 |
Levi Walker |
walker.lw31@gmail.com |
Winterset |
Madison |
Iowa |
Morgan Walker |
Drew Van Laar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Levi Walker |
walker.lw31@gmail.com |
self |
Winterset |
Madison |
Iowa |
Morgan Walker |
Drew Van Laar |
Signed |
616 |
2021-08-23 13:14 |
Anonymous (not verified) |
173.25.153.19 |
Levon |
Proprietorship |
210 S 41st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Levon shheba |
sheebalevon@gmail.com |
West des Moines IA 50265 |
Polk county |
IA |
Alina sheeba |
Delon sheeba |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Levon sheeba |
sheebalevon@gmail.com |
Myself |
West des Moines IA 50265 |
Polk county |
IA |
Alina sheeba |
Delon sheeba |
Signed |
1725 |
2023-07-07 13:37 |
Anonymous (not verified) |
94.188.205.167 |
Liana Fatino |
Limited Liability Company |
1930 se 14th des moines iowa 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. |
2023-07-07 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
USA |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
wife |
des moines |
USA |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
1734 |
2023-07-11 08:25 |
Anonymous (not verified) |
94.188.207.226 |
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 |
Liana Fatino |
lfatino@yahoo.com |
Des Moines |
Polk |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
owner |
des moines |
polk |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
1736 |
2023-07-11 08:30 |
Anonymous (not verified) |
94.188.207.228 |
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 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
owner |
des moines |
polk |
IOWA |
Liana Fatino |
Gary Fatino |
Signed |
2103 |
2024-03-18 12:33 |
Anonymous (not verified) |
94.188.205.177 |
Scornos 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 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
GARY FATINO |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
GARY FATINO |
lfatino@yahoo.com |
husband |
des moines |
polk |
iowa |
Gary Fatino |
Lisa Vacco |
Signed |
2105 |
2024-03-18 12:45 |
Anonymous (not verified) |
94.188.205.169 |
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 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
GARY FATINO |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
GARY FATINO |
lfatino@yahoo.com |
husband |
des moines |
polk |
iowa |
Gary Fatino |
Lisa Vacco |
Signed |
466 |
2021-04-08 09:58 |
Anonymous (not verified) |
216.81.153.249 |
Supreme Express Transport LLC |
Limited Liability Company |
609 Euclid Ave, Cherokee, IA 51012 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Liana Gil |
liana2702@gmail.com |
Cherokee |
Cherokee |
Iowa |
Leigh Laven |
Jared Brashears |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Gill |
liana2702@gmail.com |
Owner |
Cherokee |
Cherokee |
Iowa |
Leigh Laven |
Jared Brashears |
Signed |
1553 |
2023-04-04 14:52 |
Anonymous (not verified) |
94.188.205.177 |
TOPSOIL OUTDOOR SERVICES |
Limited Liability Company |
4919 SCHUBERT 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. |
2023-04-04 |
LIBAN |
topsoiloutdoor@gmail.com |
AMES |
IA |
United States |
Liban Wetzberger |
Liban Wertzberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liban Wertzberger |
topsoiloutdoor@gmail.com |
Owner |
AMES |
IA |
United States |
Liban Wertzberger |
Liban Wertzberger |
Signed |
678 |
2021-10-18 11:26 |
Anonymous (not verified) |
69.18.40.109 |
MR&E,llc |
Limited Liability Company |
2501 Summer 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. |
2021-10-18 |
Linda Hunter |
whitandpayt@gmail.com |
Burlington |
IA |
United States |
Kim Delap |
Teri Coleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcie Bollin Gaylord |
avisburlington@hotmail.com |
President |
FORT MADISON |
IA |
United States |
Kim Delap |
Teri Coleman |
Signed |
223 |
2020-08-05 13:22 |
Anonymous (not verified) |
173.28.28.57 |
Shear Beautique Retail, LLC |
Limited Liability Company |
910 Parriott, 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. |
2020-07-28 |
Lindsey Poppens |
cmins_re@mchsi.com |
Allison |
BUTLER |
Iowa |
Thomas R Poppens |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lindsey Poppens |
cmins_re@mchsi.com |
Self |
Allison |
Butler |
Iowa |
Thomas R Poppens |
Roxanne Kolder |
Signed |
1923 |
2023-11-27 11:21 |
Anonymous (not verified) |
94.188.207.230 |
Chilled LLC |
Limited Liability Company |
236 Meadow Breeze Ln Center Point IA 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. |
2023-11-27 |
Lindsy J Trotter |
Lindsy@chilledfreezermeals.com |
Center Point |
Linn |
Iowa |
Abbie Snakenberg |
Amanda Guttau |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lindsy Trotter |
Lindsy@chilledfreezermeals.com |
Owner |
Center Point |
Linn |
Iowa |
Abbie Snakenberg |
Amanda Guttau |
Signed |
2115 |
2024-03-26 14:53 |
Anonymous (not verified) |
94.188.207.223 |
DICKINSON COUNTY CLEANING AND MAINTENANCE, LLC |
Limited Liability Company |
414 19TH ST PO BOX 182 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. |
2024-03-26 |
LISA ARROWOOD |
lisa.arrowood1126@gmail.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LISA ARROWOOD |
lisa.arrowood1126@gmail.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
51 |
2020-02-04 10:31 |
Anonymous (not verified) |
173.28.28.57 |
Sister Style, LLC |
Limited Liability Company |
211 3rd Street, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-23 |
Lisa Ellis |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisa Ellis |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
477 |
2021-04-14 11:04 |
Anonymous (not verified) |
65.103.82.36 |
Lisa Kuhn |
Proprietorship |
427 s Concord 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. |
2020-01-09 |
Lisa Kuhn |
none@hotmail.com |
davenport |
Scott |
IA |
Sarah |
Erick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisa Kuhn |
none@hotmail.com |
self |
davenport |
scott |
IA |
sarah |
erick |
Signed |
1772 |
2023-08-01 15:09 |
Anonymous (not verified) |
94.188.205.168 |
MHI Services |
Proprietorship |
613 Damon St 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. |
2023-08-01 |
Lisa Mitchell |
lmitchell939@gmail.com |
Council Bluffs |
Pottawattamie |
Iowa |
Charles Meckna |
Christopher Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LIsa MItchellj |
lmitchell939@gmail.com |
Self |
Council Bluffs |
Pottawattamie |
Iowa |
Charles Meckna |
Christopher Young |
Signed |
372 |
2021-01-25 08:38 |
Anonymous (not verified) |
66.188.136.150 |
Sawa Cheroke Transport, LLC |
Limited Liability Company |
PO Box 168, Stilwell, OK 74960 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Lisa Pritchett |
kschumacher@tricorinsurance.com |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sawa Cheroke Transport, LLC |
kschumacher@tricorinsurance.com |
Same |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
861 |
2022-01-27 11:33 |
Anonymous (not verified) |
69.63.16.2 |
Dreams 2 Reality Construction LLC |
Limited Liability Company |
17615 Meredith Dr, Waukee, IA 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-26 |
Lisa Rubsam |
lisa@dreams2reality.us |
Waukee |
Dallas |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisa Rubsam |
lisa@dreams2reality.us |
Member |
Waukee |
Dallas |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
2114 |
2024-03-25 18:18 |
Anonymous (not verified) |
94.188.207.227 |
Lisa V Blessington |
Proprietorship |
411 S 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. |
2024-03-25 |
Lisa Varie Blessington |
lblessington@yahoo.com |
Sac City |
Sac |
IA |
Jean Rexroat |
Jennifer Tovar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisa Varie Blessington |
lblessington@yahoo.com |
Same |
Sac City |
Sac |
IA |
Jean Rexroat |
Jennifer Tovar |
Signed |
257 |
2020-09-14 16:15 |
Anonymous (not verified) |
66.129.217.166 |
Lisseth Carolina Salas Melendez |
Proprietorship |
3107 M & W Crl Muscatine, 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. |
2020-01-01 |
Lisseth Carolina Salas Melendez |
chonrosales88@gmail.com |
Muscatine |
Louisa |
IA |
Rafael Crespo |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisseth Carolina Salas Melendez |
chonrosales88@gmail.com |
Same |
Muscatine |
Louisa |
IA |
Rafael Crespo |
Anthony Johnson |
Signed |
346 |
2020-12-31 10:39 |
Anonymous (not verified) |
66.129.217.166 |
GIL Construction, LLC |
Limited Liability Company |
3107 M & W Crl, 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. |
2020-10-20 |
Lisseth Melendez Gil |
chonrosales88@gmail.com |
Muscatine |
Iowa |
United States |
Donis Medina |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisseth Melendez Gil |
chonrosales88@gmail.com |
Owner |
Muscatine |
Iowa |
United States |
Donis Medina |
Anthony Johnson |
Signed |
384 |
2021-02-03 20:36 |
Anonymous (not verified) |
66.129.217.166 |
GIL Construction, LLC |
Limited Liability Company |
3107 M & W Crl |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Lisseth Melendez Gil |
tonypauljohnson@yahoo.com |
Muscatine |
Iowa |
United States |
Rafael Medina |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisseth Melendez Gil |
tonypauljohnson@yahoo.com |
Owner |
North Liberty |
IA |
United States |
Rafael Medina |
Anthony Johnson |
Signed |
1208 |
2022-07-15 11:06 |
Anonymous (not verified) |
173.18.22.217 |
JL Elite Painting |
Limited Liability Company |
3416 NW 20th 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. |
2022-07-15 |
Lizeth Benitez |
jl.elite.painting@gmail.com |
Ankeny |
Polk |
IA |
Lesa Reeves |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lizeth Benitez |
jl.elite.painting@gmail.com |
owner |
Ankeny |
Polk |
IA |
Lesa Reeves |
Kelly Coluzzi |
Signed |
1596 |
2023-04-24 15:48 |
Anonymous (not verified) |
94.188.205.174 |
Loyal Transport INC |
Proprietorship |
1987 Middle Calmar Road, 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. |
2022-02-01 |
Lloyd Bjergum |
aryan1950@hotmail.com |
Decorah, IA |
Winneshiek |
Iowa |
Allen Monroe |
Amy Ryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lloyd Bjergum |
aryan1950@hotmail.com |
Self |
Decorah, |
Winneshiek |
Iowa |
Allen Monroe |
Amy Ryan |
Signed |
375 |
2021-01-25 16:03 |
Anonymous (not verified) |
66.188.136.150 |
Logan Beauregard |
Proprietorship |
615 Oak Ave N, Onalaska, WI 54650 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Logan Beauregard |
kschumacher@tricorinsurance.com |
Onalaska |
La Crosse |
WI |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Logan Beauregard |
kschumacher@tricorinsurance.com |
Same |
Onalaska |
La Crosse |
WI |
Russell Masartis |
Shuree Behr |
Signed |
265 |
2020-09-21 14:41 |
Anonymous (not verified) |
74.84.65.174 |
Nagol Enterprises |
Limited Liability Company |
16124 PLEASANT 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. |
2020-09-21 |
Logan Victor Ante |
antelogan@gmail.com |
Story CIty |
Story |
iowa |
Brian Wade Warren |
Tyler Christian Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Logan Victor Ante |
antelogan@gmail.com |
Same |
Story CIty |
IA |
IA |
Brian Wade Warren |
Tyler Christian Thompson |
Signed |
100 |
2020-03-24 15:46 |
Anonymous (not verified) |
216.51.130.87 |
Lake City Electric, LLC |
Limited Liability Company |
113 E Main Street, Lake City, IA 51449 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-24 |
Lonnie R. Daisy |
lcelectric@iowatelecom.net |
Lake City |
Calhoun |
IOWA |
Sheryl Lynch |
Karen Prebeck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lonnie R. Daisy |
lcelectric@iowatelecom.net |
self |
Lake City |
Calhoun |
IOWA |
Sheryl Lynch |
Karen Prebeck |
Signed |
1865 |
2023-10-09 10:28 |
Anonymous (not verified) |
94.188.205.166 |
Lori Martinez |
Proprietorship |
6650 SE 5 TH STREET 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. |
2023-10-09 |
Lori Martinez |
azulbenavidez04@gmail.com |
Des Moines |
Polk |
Iowa |
R. Mitch Coluzzi |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Martinez |
azulbenavidez04@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
R. Mitch Coluzzi |
Jennifer Lambert |
Signed |
2014 |
2024-01-31 15:17 |
Anonymous (not verified) |
94.188.205.174 |
Aspen Ridge LLC |
Limited Liability Company |
1404 G 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. |
2023-05-10 |
Lori McKusker |
lori@mckuskerelectric.com |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori McKusker |
jeff@mckuskerelectric.com |
Self |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
1906 |
2023-11-14 13:47 |
Anonymous (not verified) |
94.188.207.223 |
HRBC Plus |
Limited Liability Company |
249 SOLOMIA CT, Peosta, IA 52068 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-11 |
Lori S Stewart |
lori@hrbcplus.com |
PEOSTA |
Dubuque |
United States |
Mark R Stewart |
Danielle M Leibfried |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Stewart |
lori@hrbcplus.com |
Self |
Peosta |
Dubuque |
United States |
Mark R Stewart |
Danielle M Peterson |
Signed |
11 |
2019-12-17 19:46 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Louis I. Maxwell |
brockbrooke2463@yahoo.com |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Louis Maxwell |
brockbrooke2463@yahoo.com |
Owner |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
134 |
2020-04-28 08:15 |
Anonymous (not verified) |
66.188.136.150 |
Lowell Fenton |
Proprietorship |
404 1/2 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. |
2020-04-27 |
Lowell Fenton |
fentonlowell@gmail.com |
Decorah |
Winneshiek |
IA |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lowell Fenton |
kschumacher@tricorinsurance.com |
Same person |
Decorah |
Winneshiek |
IA |
Russell Masartis |
Shuree Behr |
Signed |
1776 |
2023-08-03 13:51 |
Anonymous (not verified) |
94.188.207.224 |
Lucas Adam Peterson |
Proprietorship |
2833 SE 68th St 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. |
2023-08-03 |
Lucas Adam Peterson |
Luke.Peterson.mzub@gmail.com |
Pleasant Hill |
POLK |
IOWA |
Sarah Peterson |
Samuel Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucas Adam Peterson |
Luke.Peterson.mzub@gmail.com |
Self |
PLEASANT HILL |
IA |
United States |
Sarah Peterson |
Samuel Peterson |
Signed |
2220 |
2024-05-10 11:10 |
Anonymous (not verified) |
94.188.207.229 |
Froyo To Go, LLC |
Limited Liability Company |
909 4th Ave S., 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. |
2024-05-10 |
Lucas Gillmor |
lgillmor@dmuonline.com |
Denison |
Crawford |
Iowa |
Maria Sandoval |
Nahomy Fernandez Alvarado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trevis Beeck |
trevis.beeck.u0ms@statefarm.com |
State Farm Agent |
Denison |
Crawford |
Iowa |
Maria Sandoval |
Nahomy Fernandez Alvarado |
Signed |
273 |
2020-10-05 13:57 |
Anonymous (not verified) |
173.30.54.139 |
Jackson Exteriors |
Proprietorship |
705 Cherry Avenue Woodward,ia 50276 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-05 |
Lucas Jackson |
ljajackson41977@gmail.com |
Woodward |
IA |
United States |
Cody Roth |
Dustin Perry |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucas Jackson |
ljajackson41977@gmail.com |
Owner |
Woodward |
Dallas |
United States |
Cody Roth |
Dustin perry |
Signed |
998 |
2022-03-23 08:34 |
Anonymous (not verified) |
104.201.100.158 |
L Peterson Insurance, LLC |
Limited Liability Company |
603 Pleasant View Drive 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. |
2022-03-23 |
Lucas Peterson |
lpeterson@phillipsstafford.com |
Des Moines |
Polk |
Iowa |
Luke Van Roekel |
Sam Debartolo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucas Peterson |
lpeterson@phillipsstafford.com |
Owner |
Des Moines |
Polk |
Iowa |
Luke Van Roekel |
Sam Debartolo |
Signed |
1215 |
2022-07-20 13:43 |
Anonymous (not verified) |
173.21.133.45 |
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. |
2022-07-20 |
Lucia A Hughes |
lucyh68313@gmail.com |
Ottumwa |
Wapello |
Iowa |
Katy Knott |
Doug Knott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RJ Hallman |
rjhallman@fedins.com |
Insurance |
Owatonna |
Steele |
Minnesota |
Katy Knott |
Doug Knott |
Signed |
1306 |
2022-09-13 15:50 |
Anonymous (not verified) |
96.31.1.206 |
LUCIO PAINTING |
Proprietorship |
818 W 4TH ST 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. |
2022-09-06 |
LUCIO PENA |
joel@walkerinsuranceia.com |
SPENCER |
CLAY |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LUCIO PENA |
joel@walkerinsuranceia.com |
SELF |
SPENCER |
CLAY |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1176 |
2022-07-05 08:08 |
Anonymous (not verified) |
64.251.168.116 |
Lucky Dude |
Proprietorship |
27656 SD Hwy 44 WHITE RIVER SD 57579 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Lucky Dude |
agflyer620@gwtc.net |
White River |
Mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucky Dude |
agflyer620@gwtc.net |
proprietor |
White River |
mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
1449 |
2023-02-11 10:37 |
Anonymous (not verified) |
94.188.207.227 |
Luxury Home Improvements |
Limited Liability Company |
4117 Boyd 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. |
2023-01-11 |
Luis A Hernandez |
luxuryhomes.iowa@gmail.com |
Des Moines |
Polk |
Iowa |
Maria T Lopez |
Josmar Hernandez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis A Hernandez |
luxuryhomes.iowa@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Maria T Lopez |
Josmar Hernandez |
Signed |
1579 |
2023-04-17 17:00 |
Anonymous (not verified) |
94.188.205.177 |
Home provisions siding LLC |
Limited Liability Company |
1816 Francis avenue apt 1 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Luis Alberto Ramirez Mendez |
luisramirez4308@icloud.com |
Desmoines |
Polk |
Iowa |
Alexandra Gomez-Benitez |
Marcedez ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis Alberto Ramirez Mendez |
luisramirez4308@icloud.com |
None |
Des Moines |
Polk |
Iowa |
Alexandra Gomez-Benitez |
Marcedez Roxana Ramirez |
Signed |
2049 |
2024-02-16 09:19 |
Anonymous (not verified) |
94.188.205.169 |
Cadona Construction LLC |
Limited Liability Company |
215 S Leonard, Sioux City, IA 51103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-16 |
Luis Cardona |
luiscardona5151@gmail.com |
Sioux City |
Woodbury |
Iowa |
Kyle Buum |
David Jacobs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis Cardona |
luiscardona5151@gmail.com |
Owner |
Sioux City |
Woodbury |
Iowa |
Kyle Buum |
David Jacobs |
Signed |
1599 |
2023-04-25 14:38 |
Anonymous (not verified) |
94.188.207.229 |
luis contreras |
Proprietorship |
433 8th 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. |
2023-04-25 |
luis contreras |
luisayala781@gmail.com |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
luis contreras |
luisayala781@gmail.com |
N/A |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
1597 |
2023-04-24 16:03 |
Anonymous (not verified) |
94.188.207.224 |
4 Iowa Construction LLC |
Limited Liability Company |
1750 Lyon 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. |
2023-04-24 |
Luis E Cancino Mireles |
luiscancino55@gmail.com |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis E Cancino Mireles |
luiscancino55@gmail.com |
self / 100% owner / manager of the LLC |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
1981 |
2024-01-10 22:12 |
Anonymous (not verified) |
94.188.205.175 |
Level Up Renovations LLC |
Limited Liability Company |
648 31st Street, 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. |
2024-01-10 |
Luis Humberto Cazares Lopez |
leveluprenovationsia@outlook.com |
Des Moines |
Polk |
Iowa |
Gabriela Joanne Cazares |
Raquel Medina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis Humberto Cazares Lopez |
leveluprenovationsia@outlook.com |
Owner |
Des Moines |
Polk |
Iowa |
Gabriela Joanne Cazares |
Raquel Medina |
Signed |
338 |
2020-12-13 16:31 |
Anonymous (not verified) |
107.77.161.48 |
LAVH LLC |
Limited Liability Company |
1520 E Pleasant View 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. |
2020-12-13 |
Luis Vasquez |
vasquezluis239@gmail.com |
Des Moines |
Polk |
Iowa |
Lorena Aguilar |
Carlos Mendoza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LAVH LLC |
vasquezluis239@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Lorena Aguilar |
Carlos Mendoza |
Signed |
583 |
2021-07-23 12:37 |
Anonymous (not verified) |
206.72.45.27 |
S&L Finishers LLC |
Limited Liability Company |
307 N 5th Street Mallard Ia 50562 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Luke AKRIDGE |
akridgel@ncn.net |
Mallard |
Palo Alto |
United States |
Kennedy Origer |
Andy Wiita |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke AKRIDGE |
akridgel@ncn.net |
Owner |
MALLARD |
IA |
United States |
Kennedy Origer |
Andy Wiita |
Signed |
284 |
2020-10-21 12:52 |
Anonymous (not verified) |
207.177.50.27 |
Luke Croghan |
Proprietorship |
2404 2200th street ,Manilla Ia. 51454 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
luke F Croghan |
croghanluke@gmail.com |
manilla |
Shelby |
Iowa |
Amy Hansen |
Todd Stadlander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
luke F Croghan |
croghanluke@gmail.com |
Owner |
manilla |
Shelby |
Iowa |
Amy Hansen |
Todd Stadlander |
Signed |
1898 |
2023-11-09 09:56 |
Anonymous (not verified) |
94.188.207.227 |
RC Restoration LLC |
Limited Liability Company |
991 June Drive, 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. |
2023-11-09 |
Luke Hoffmann |
luke@rentcube.com |
Dubuque |
Dubuque |
Iowa |
Randi Taylor |
Carla Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Hoffman |
luke@rentcube.com |
Owner |
Dubuque |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
1538 |
2023-03-27 15:20 |
Anonymous (not verified) |
94.188.205.167 |
Luke Woods |
Limited Liability Company |
1513 Burnett Station 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. |
(1) I am not electing the employers’ liability coverage. |
2023-03-27 |
Luke James Woods |
woodsmencontractingllc@gmail.com |
Central City |
Linn |
Iowa |
Keith John Woods |
Heath John Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke James Woods |
woodsmencontractingllc@gmail.com |
same person |
Central City |
Linn |
Iowa |
Keith John Woods |
Heath John Woods |
Signed |
999 |
2022-03-23 08:39 |
Anonymous (not verified) |
104.201.100.158 |
Van Roekel Insurance |
Limited Liability Company |
25919 330th Ct, Adel Iowa 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. |
2022-03-23 |
Luke Jon Van Roekel |
Lvanroekel@phillipsstafford.com |
Adel |
Dallas |
Iowa |
Megan Van Roekel |
Luke Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Jon Van Roekel |
lvanroekel@phillipsstafford.com |
Owner |
Adel |
IA |
United States |
Megan Van Roekel |
Luke Peterson |
Signed |
301 |
2020-10-30 10:53 |
Anonymous (not verified) |
216.51.132.207 |
Joe Kann & Luke Kann |
Partnership |
32256 Leaf Rd Guttenberg IA 52052 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-27 |
Luke Kann |
kannbros1895@gmail.com |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Kann |
kannbros1895@gmail.com |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
1063 |
2022-04-21 08:23 |
Anonymous (not verified) |
207.155.112.81 |
Prudenterra, LLC |
Limited Liability Company |
65584 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-04-21 |
Luke Robert Gran |
luke@prudenterra.com |
Nevada |
Story |
Iowa |
Michael Joseph Coverdale |
Judy Rae Coverdale |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Luke Robert Gran |
luke@prudenterra.com |
Self |
Nevada |
Story |
Iowa |
Michael Joseph Coverdale |
Judy Rae Coverdale |
Signed |
2222 |
2024-05-13 11:12 |
Anonymous (not verified) |
94.188.205.176 |
Fresh Painting LLC |
Limited Liability Company |
1310 5th 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. |
2023-05-13 |
Luke Stougard |
freshpaintingdsm@gmail.com |
Des Moines |
Polk |
Iowa |
Adam Bogi |
Lance Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Stougard |
freshpaintingdsm@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Adam Bogi |
Lance Webster |
Signed |
46 |
2020-01-28 16:32 |
Anonymous (not verified) |
173.18.3.76 |
Delic Marble and Tile LLC |
Limited Liability Company |
24 Ellefson Dr PO Box 413 DeSoto, IA 50069 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-01-27 |
Lutfija Delic |
delicgraniteandtile@gmail.com |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adin Delic |
delicgraniteandtile@gmail.com |
LLC Member |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
806 |
2021-12-20 08:56 |
Anonymous (not verified) |
50.124.217.66 |
Lyndon L Giese dba G&G Farms Trucking |
Proprietorship |
402 St Olaf Ave S 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. |
2021-12-20 |
Lyndon L Giese |
ldgiese@frontiernet.net |
Canby |
Yellow Medicine |
Minnesota |
Jeff Sinn |
Tiffany Gohr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lyndon L Giese |
ldgiese@frontiernet.net |
Owner |
Canby |
Yellow Medicine |
Minnesota |
Jeff Sinn |
Tiffany Gohr |
Signed |
1230 |
2022-07-27 08:59 |
Anonymous (not verified) |
108.217.146.87 |
Hunter Flying Service |
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. |
2022-07-27 |
Lynn Cary |
hunterflying@att.net |
Hunter |
Woodruff |
United States |
Karen Gifford |
Jason White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lynn Cary |
hunterflying@att.net |
Owner |
Hunter |
AR |
United States |
Karen Gifford |
Jason White |
Signed |
5 |
2019-11-12 09:57 |
Anonymous (not verified) |
174.71.54.19 |
M AND J LLC |
Limited Liability Company |
44100 STATE 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. |
2019-11-12 |
M AND J, LLC |
mknichols2003@yahoo.com |
DUNLAP |
MONONA |
IA |
Damon Nichols |
Bob Hall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JAMES MUMM |
plipichok@yahoo.com |
Partner |
DUNLAP |
MONONA |
IA |
DAMON NICHOLS |
BOB HALL |
Signed |
524 |
2021-05-17 22:41 |
Anonymous (not verified) |
166.181.84.162 |
Laven Construction LLC |
Limited Liability Company |
4935 NE 78th Ave Bondurant, Iowa 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. |
2021-05-17 |
MacKale Laven |
maclaven@gmail.com |
Bondurant |
Polk |
Iowa |
John Smith |
Cameron Thede |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MacKale Laven |
maclaven@gmail.com |
Owner |
Bondurant |
Polk |
Iowa |
Cameron Thede |
John Smith |
Signed |
1926 |
2023-11-29 10:45 |
Anonymous (not verified) |
94.188.207.224 |
M&M Janitorial LLC |
Limited Liability Company |
243 28th St Dr 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. |
2023-11-29 |
Mackenzie Willits |
mackenziewillits@gmail.com |
Cedar Rapids |
Linn |
United States |
Fransisco ruiz |
Alexander ruiz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meyling willits |
mackenziewillits@gmail.com |
Owner |
cedar rapids |
Linn |
United States |
Alexander ruiz |
Francisco ruiz |
Signed |
262 |
2020-09-18 13:54 |
Anonymous (not verified) |
75.162.229.152 |
Morgan Group LLC |
Limited Liability Company |
1124 7th 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. |
2020-09-18 |
Mackinley Charles Morgan |
MORGANGROUPLLC@GMAIL.COM |
West Des Moines |
Polk |
Iowa |
Mark Steven Morgan |
Deborah Renee Morgan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mackinley Charles Morgan |
MorganGroupLLC@gmail.com |
Owner of Company |
West Des Moines |
Polk |
Iowa |
Mark Steven Morgan |
Deborah Renee Morgan |
Signed |
640 |
2021-09-16 22:43 |
Anonymous (not verified) |
97.125.255.204 |
Morgan Group LLC |
Limited Liability Company |
1124 7th St. 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. |
2021-09-16 |
Mackinley Charles Morgan |
Morgangroupllc@gmail.com |
West Des Moines |
Polk |
Iowa |
Deborah Renee Morgan |
Mark Steven Morgan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mackinley Charles Morgan |
Morgangroupllc@gmail.com |
Owner of company |
West Des Moines |
Polk |
Iowa |
Deborah Renee Morgan |
Mark Steven Morgan |
Signed |
520 |
2021-05-17 10:32 |
Anonymous (not verified) |
50.82.130.211 |
Madison Oldenburger |
Proprietorship |
809 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. |
2021-05-06 |
Madison Oldenburger |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Madison Oldenburger |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
884 |
2022-02-02 14:10 |
Anonymous (not verified) |
104.201.67.178 |
Magdalena Lopez Raymundp |
Proprietorship |
2820Pennsylvania Ave, 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. |
2022-01-01 |
Magdalena Lopez Raymundo |
scottthomascpa@msn.com |
Dubuque |
Dubuque |
Iowa |
Rich Darr |
Mari Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott D Thomas |
scottthomascpa@msn.com |
Consultant |
West Des Moines |
IA |
United States |
Rich Darr |
Mari Lopez |
Signed |
676 |
2021-10-15 11:29 |
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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-10-15 |
MANUEL CONTRERAS BERNAL |
MCGFLOORINGLLC@GMAIL.COM |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
MCG FLOORING, LLC |
MCGFLOORINGLLC@GMAIL.CON |
OWNER |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
2107 |
2024-03-19 12:33 |
Anonymous (not verified) |
94.188.205.175 |
Elit Construction and Masonry LLC |
Partnership |
3309 Wright 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. |
2023-03-19 |
Manuel Mejia |
elitconstructionmasonryllc@gmail.com |
Des Moines |
Polk |
Iowa |
Heather Garber |
Kyle Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Mejia |
elitconstructionmasonryllc@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Heather Garber |
Kyle Johnson |
Signed |
2136 |
2024-04-04 16:08 |
Anonymous (not verified) |
94.188.205.169 |
Elite Construction & Masonry LLC |
Limited Liability Company |
3309 Wright 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. |
2024-04-04 |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
648 |
2021-09-21 10:03 |
Anonymous (not verified) |
97.125.32.164 |
Manuel Morales |
Proprietorship |
1302 13th St Des Moines, Iowa 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. |
2021-09-15 |
Manuel Morales |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Morales |
deb@picowa.com |
subcontractor |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
2043 |
2024-02-13 13:38 |
Anonymous (not verified) |
94.188.207.226 |
mannys handyman services |
Limited Liability Company |
3084 120th st cumming ia 50061 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-13 |
manuel v banegas |
mannyshandymanservices.ia@gmail.com |
cumming |
3084 120th st |
iowa |
Adam Boge |
Lance Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
manuel v banegas |
mannyshandymanservices.ia@gmail.com |
self employeed |
Cumming |
Madison |
Iowa |
Adam Boge |
Lance Webster |
Signed |
1202 |
2022-07-11 21:14 |
Anonymous (not verified) |
173.17.252.144 |
B SQUARED CONSTRUCTION |
Limited Liability Company |
3407 skyline 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. |
2022-07-11 |
MARC BROOKER |
BSquared066@gmail.com |
Des Moines |
United states |
IA |
marc brooker |
MARC BROOKER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MARC BROOKER |
BSquared066@gmail.com |
owner |
Des Moines |
IA |
IA |
MARC BROOKER |
MARC BROOKER |
Signed |
1368 |
2022-11-11 11:58 |
Anonymous (not verified) |
173.29.231.17 |
Marcelino Gutierrez |
Proprietorship |
1705 Des Moines Street, 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. |
2022-11-11 |
Marcelino Gutierrez |
lifestylefloors20@gmail.com |
Des Moines |
Polk |
Iowa |
Jerry Downing |
Ashley Temple |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcelino Gutierrez |
Lifestylefloors20@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Jerry Downing |
Ashley Downing |
Signed |
380 |
2021-02-01 15:04 |
Anonymous (not verified) |
192.30.185.142 |
Chelos Framing Crew |
Proprietorship |
501 Colon Street, Sioux City, 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. |
2021-02-01 |
Marcelo Lopez |
chelosframingcrew@icloud.com |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcelo Lopez |
chelosframingcrew@icloud.com |
Owner |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Virginia Anderson |
Signed |
677 |
2021-10-18 11:09 |
Anonymous (not verified) |
69.18.40.109 |
MR&E,llc |
Limited Liability Company |
2501 Summer 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. |
2021-10-18 |
Marcie R Gaylord |
avisburlington@hotmail.com |
Fort Madison |
IA |
United States |
Kim Delap |
Teri Coleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcie Bollin Gaylord |
avisburlington@hotmail.com |
President |
FORT MADISON |
Lee |
Iowa |
Kim Delap |
Teri Coleman |
Signed |
2099 |
2024-03-15 18:50 |
Anonymous (not verified) |
94.188.205.174 |
OMG Bros, LLC |
Limited Liability Partnership |
404 Ivanhoe Rd, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-03-15 |
Marco Antonio Gaytan |
marcogaytan77@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Kaden Lyle |
Arayely Vazquez |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tristan Anthony Siebrands |
omgservices@omgbros.org |
Partner |
Waterloo |
Black Hawk |
Iowa |
Kaden Lyle |
Arayely Vazquez |
Signed |
2169 |
2024-04-22 09:49 |
Anonymous (not verified) |
94.188.205.166 |
Galatic Service LLC |
Proprietorship |
623 1st street silvis IL 61282 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Marcos Gonzales |
Marcosg300@yahoo.com |
Silvis |
Rock Island |
IL |
Jordan lyod |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas city |
Johnson |
MO |
Marcos Gonzales |
Jordan Lyod |
Signed |
880 |
2022-02-01 14:05 |
Anonymous (not verified) |
207.45.88.5 |
Known Labs LLC |
Limited Liability Partnership |
8350 Ep True Pkwy, UNIT 1201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Marcus Antonio Smith |
mark@knownlabs.net |
West Des Moines |
Dallas |
IA |
Dan Morgan III |
Amber Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcus Antonio Smith |
mark@knownlabs.net |
Owner |
West Des Moines |
IA |
IA |
Daniel Morgan III |
Amber Smith |
Signed |
2089 |
2024-03-12 10:58 |
Anonymous (not verified) |
94.188.205.166 |
Margarito R Guzman |
Proprietorship |
4512 S 22nd ST Omaha NE 68107 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-12 |
Margarito R Guzman |
abrahamguzman030@gmail.com |
omaha |
douglas |
NE |
jose abraham guzman garcia |
Drakkar Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Margarito Guzman |
abrahamguzman030@gmail.com |
Owner |
Omaha |
Douglas |
Nebraksa |
jose abraham guzman garcia |
Drakkar Rapaich |
Signed |
885 |
2022-02-02 14:13 |
Anonymous (not verified) |
104.201.67.178 |
Maria DeLeon |
Proprietorship |
2805 10th Avenue North, 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. |
2022-01-01 |
Maria DeLeon |
scottthomascpa@msn.com |
Fort Dodge |
Webster |
Iowa |
Rich Darr |
Mari Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott D Thomas |
s.thomas@nationwideofficecare.com |
Consultant |
West Des Moines |
IA |
United States |
Rich Darr |
Mari Lopez |
Signed |
1220 |
2022-07-21 13:12 |
Anonymous (not verified) |
172.58.83.160 |
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. |
2022-07-21 |
María Duarte |
mariacabrera515@icloud.com |
Ottumwa |
Wapello |
Iowa |
Katy Knott |
Doug Knott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RJ Hallman |
rjhallman@fedins.com |
Insurance |
Owatonna |
Steele |
Minnesota |
Katy Knott |
Doug Knott |
Signed |
938 |
2022-02-25 15:21 |
Anonymous (not verified) |
174.215.247.215 |
Maria castillo |
Limited Liability Company |
2200 scott blvd #90 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. |
2022-09-25 |
Maria evangelina castillo moreno |
mariacastillo852@yahoo.com |
Iowa city |
Jonhson |
Iowa |
Maria castillo |
Emilio Castillo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maria evangelina castillo moreno |
mariacastillo852@yahoo.vom |
Work |
Iowa city |
Johnson |
Iowa |
Maria castillo |
Emilio Castillo |
Signed |
1870 |
2023-10-17 16:13 |
Anonymous (not verified) |
94.188.205.176 |
Diamond ridge |
Proprietorship |
1842 Glenwood cir 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. |
2023-10-17 |
Marianna Landeros |
cheri6876@yahoo.com |
Des moines |
Polk |
Iowa |
Marianna Landeros |
Cheri Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marianna Landeros |
landerosmary@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Cheri Martinez |
Jessica Newton |
Signed |
868 |
2022-01-28 12:22 |
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 |
Marie Elsbernd |
lacy@cioia.com |
Calmar |
Winneshiek |
Iowa |
Joel Rochford |
Lacy Carolan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marie Elsbernd |
lacy@cioia.com |
Spouse |
Calmar |
Winneshiek |
Iowa |
Joel Rochford |
Lacy Carolan |
Signed |
1998 |
2024-01-25 16:18 |
Anonymous (not verified) |
94.188.205.168 |
Faith and Trust Soulutions LLC |
Limited Liability Company |
139 37th Street NE Suite # 2 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-25 |
Marie Moore |
faithandtrustsoulutionsllc@gmail.com |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arthur Barbine |
faithandtrustsoulutionsllc@gmail.com |
Friend |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
2050 |
2024-02-16 09:45 |
Anonymous (not verified) |
94.188.207.224 |
Mario Construction |
Limited Liability Company |
1755 Huntington Rd 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. |
2024-02-16 |
Mario Lainez |
brocalainez73@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Karolina Saenz |
Alejandra Maradiaga |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mario Lainez |
brocalainez73@gmail.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Karolina Saenz |
Alejandra Maradiaga |
Signed |
1750 |
2023-07-17 11:00 |
Anonymous (not verified) |
94.188.205.166 |
Mario Flores |
Proprietorship |
2101 E Virginia Ave. Apt 1 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. |
2021-07-22 |
Mario Zubia Flores |
deb@piciowa.com |
Des Moiines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mario Zubia Flores |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
1751 |
2023-07-17 11:00 |
Anonymous (not verified) |
94.188.205.166 |
Mario Flores |
Proprietorship |
2101 E Virginia Ave. Apt 1 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. |
2021-07-22 |
Mario Zubia Flores |
deb@piciowa.com |
Des Moiines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mario Zubia Flores |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Inspro employee 2022 |
Inspro employee 2022 |
Signed |
145 |
2020-04-30 16:09 |
Anonymous (not verified) |
173.191.206.253 |
Mark Knapp |
Proprietorship |
11244 Linden Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-30 |
Mark A Knapp |
mlmlknapp@iowatelecom.net |
Linden |
Iowa |
United States |
Phil Hesseltine |
Kathy Hesseltine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Knapp |
mlmlknapp@iowatelecom.net |
self |
Linden |
Iowa |
United States |
Phil Hesseltine |
Kathy Hesseltine |
Signed |
98 |
2020-03-23 15:07 |
Anonymous (not verified) |
65.120.236.250 |
Cross Roads Logistics, LLC |
Limited Liability Company |
3103 21st 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 |
Mark Alan Cross |
rcreek2016@gmail.com |
Davenport |
IA |
IA |
Lori Ann Cross |
Barbara A Deering |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Alan Cross |
rcreek2016@gmail.com |
President/Owner |
Davenport |
IA |
IA |
Lori Ann Cross |
Barbara A Deering |
Signed |
738 |
2021-11-11 14:38 |
Anonymous (not verified) |
72.13.16.172 |
MARK ALAN SALATHE |
Proprietorship |
1042 WELLS 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. |
2019-11-18 |
MARK ALAN SALATHE |
dave@allseasonstrucking.com |
DARLINGTON |
LAFAYETTE |
WI |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MARK ALAN SALATHE |
dave@allseasonstrucking.com |
PRESIDENT |
DARLINGTON |
LAFAYETTE |
WI |
DAVE NEUWOHNER |
BEN MOYER |
Signed |
1681 |
2023-06-08 15:55 |
Anonymous (not verified) |
94.188.207.223 |
Cross Roads Builders, LLC |
Limited Liability Company |
3103 21st Street Camanche, IA.52730 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Mark Allan Cross |
rcreek2016@gmail.com |
Davenport |
iowa |
United States |
Barb Deering |
Mike Cross |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Cross |
rcreek2016@gmail.com |
Owner/President |
Davenport |
IA |
United States |
Barb Deering |
Mike Cross |
Signed |
1317 |
2022-09-21 15:04 |
Anonymous (not verified) |
184.81.198.17 |
Mark Jagnow |
Proprietorship |
2174 Rohret Rd SW Oxford 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. |
2022-09-21 |
Mark Allen Jagnow |
Mark@Jagnow.com |
Oxford |
Johnson |
Iowa |
Catherine Louise Nelson |
Joseph Roger Titone |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Allen Jagnow |
Mark@jagnow.com |
self |
Oxford |
Johnson |
Iowa |
Catherine Louise Nelson |
Joseph Roger Titone |
Signed |
126 |
2020-04-21 21:19 |
Anonymous (not verified) |
69.76.135.87 |
Merge Midwest Engineering, LLC |
Limited Liability Company |
2668 W. Catalpa 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. |
2020-04-21 |
Mark Daniel Stuempel |
mstuempel@mergemidwest.com |
Kansas City |
Wyandotte |
KANSAS |
Anna Langer |
Donna Stuempel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Janelle Clayton |
jclayton@mergemidwest.com |
LLC Member |
Olathe |
Johnson |
KS |
Anna Langer |
Donna Stuempel |
Signed |
1777 |
2023-08-03 14:21 |
Anonymous (not verified) |
94.188.207.227 |
Mark Doty |
Proprietorship |
509 Parwood Circle, 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. |
2023-08-03 |
Mark Doty |
mdoty@dakotagrown.com |
Huxley |
Story |
IA |
Rebecca R Moeller |
Jeffery F Vanasse |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rebecca R Moeller |
Becky@northernlines.net |
Agent |
Fairmont |
MN |
United States |
Rebecca R Moeller |
Jeffery F Vanasse |
Signed |
1899 |
2023-11-09 16:55 |
Anonymous (not verified) |
94.188.207.227 |
Factory Services |
Limited Liability Company |
2444 Elm 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. |
2023-11-09 |
Mark Farrell |
markfa12@yahoo.com |
Fort Dodge |
Webster |
Iowa |
Heather Farrell |
Karson Farrell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Farrell |
markfa12@yahoo.com |
Owner |
Fort Dodge |
Webster |
Iowa |
Heather Farrell |
Karson12 |
Signed |
1319 |
2022-09-22 11:31 |
Anonymous (not verified) |
50.82.91.213 |
J. Thompson Builders, LLC |
Limited Liability Company |
5291 Stoney Creek Ct. Johnston, IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-22 |
Mark Grant |
mjgrant1957@gmail.com |
Adel |
Dallas |
IA |
Christina Viehauser |
Jeremy Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christina Viehauser |
christina@jthompsonbuilders.com |
Office Help |
Johnston Ia |
Polk |
IA |
Chris Von Arx |
Jeremy Thompson |
Signed |
154 |
2020-05-12 15:00 |
Anonymous (not verified) |
97.125.253.184 |
Rundle Creations |
Limited Liability Company |
5816 Urbandale Avenue, Des Moines, 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. |
2020-05-12 |
Mark Lavern Rundle II |
rundlecreations@gmail.com |
Des Moines |
Polk |
Iowa |
Luis Alex Jimenez |
Jennifer Lea Griffith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erika Anne Rundle |
rundlecreations@gmail.com |
Co-Owner |
Des Moines |
Polk |
Iowa |
Luis Alex Jimenez |
Jennifer Lea Griffith |
Signed |
669 |
2021-10-13 08:24 |
Anonymous (not verified) |
64.191.11.62 |
E360 Building Company, Inc. |
Proprietorship |
PO Box 363, 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. |
2021-10-13 |
Mark Miller |
mark@e360buildingco.com |
Cedar Falls |
Black Hawk |
Iowa |
Laetyn Miller |
Grant Williamson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Miller |
markm@cfu.net |
Self |
Cedar Falls |
Black Hawk |
Iowa |
Laetyn Miller |
Grant Williamson |
Signed |
1338 |
2022-10-17 15:53 |
Anonymous (not verified) |
74.84.121.206 |
Mark Mitchell |
Proprietorship |
P O Box 38 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-15 |
Mark Mitchell |
darrele@ciains.biz |
New Albion |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Mitchell |
darrele@ciains.biz |
Self |
New Albion |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1144 |
2022-06-06 15:51 |
Anonymous (not verified) |
63.152.93.184 |
Mark Moser |
Limited Liability Company |
904 W 4th St., 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. |
2022-01-02 |
Mark Moser |
mpmmoser@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Timothy Combs |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Moser |
mpmmoser@gmail.com |
none |
Waterloo |
Black Hawk |
Iowa |
Timothy Combs |
Teresa Tjaden |
Signed |
4 |
2019-11-12 09:06 |
Anonymous (not verified) |
174.71.54.19 |
M AND J LLC |
Limited Liability Company |
44100 STATE HIGHWAY 37 Dunlap, IA 51529 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-12 |
Mark Nichols |
mknichols2003@yahoo.com |
DUNLAP |
Monona |
IA |
Damon Nichols |
Bob Hall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Nichols |
mknichols2003@yahoo.com |
Partner |
Dunlap |
Monona |
IA |
Damon Nichols |
Bob Hall |
Signed |
643 |
2021-09-17 11:17 |
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 |
Mark Pearson |
mdpearson88@gmail.com |
Corning |
Adams |
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 |
1801 |
2023-08-15 14:17 |
Anonymous (not verified) |
94.188.205.168 |
Mark S Lisiecki |
Proprietorship |
2526 S Arizona RD Apache Junction AZ 85119 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Mark S Lisiecki |
markslisiecki@yahoo.com |
Apache Junction |
PINAL |
Arizona |
Simona Valeriano |
Cindy Ugarte |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Lisiecki |
markslisiecki@yahoo.com |
owner |
APACHE jUNCTION |
PINAL |
AZ |
Simona Valeriano |
Cindy Ugarte |
Signed |
912 |
2022-02-14 17:51 |
Anonymous (not verified) |
72.168.160.122 |
Mark Weiss |
Proprietorship |
11461 NW Timber Way Granger Iowa 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. |
2022-02-14 |
Mark Weiss |
kkweiss77@yahoo.com |
Granger |
Polk |
Iowa |
Paul Ness |
Deb Ness |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Casi Sparks |
csparks@destinyhomesusa.com |
Subcontractor |
Waukee |
Dallas |
Iowa |
Paul Ness |
Deb Ness |
Signed |
552 |
2021-06-29 14:55 |
Anonymous (not verified) |
97.125.35.240 |
Melo Drywall |
Proprietorship |
7500 Bloomfield Road Lot 78 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. |
2021-06-25 |
Marlene Bautista |
bbautistamarbb@gmail.com |
Des Moines |
Polk |
Iowa |
Brian Pruitt |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marlene Bautista |
bbautistamarbb@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Brian Pruitt |
Kelly Denger |
Signed |
657 |
2021-09-27 13:55 |
Anonymous (not verified) |
167.142.136.87 |
Crosser Electric,Inc |
Partnership |
PO Box 204 Eldora, Iowa 50627 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-27 |
Marlyn D Crosser |
vhalvorsen@aol.com |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vicki Halvorsen |
vhalvorsen@aol.com |
Partner andf sec/treasurer |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
1520 |
2023-03-16 14:24 |
Anonymous (not verified) |
94.188.205.167 |
MMK Electric |
Partnership |
4515 84th 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. |
2023-03-16 |
Marshall Logan McKay |
mmk.iowa@gmail.com |
Des Moines |
Polk |
Iowa |
Travis Miller |
Elijah Kain |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Miller |
mmk.iowa@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Elijah Kain |
Travis Miller |
Signed |
873 |
2022-01-30 18:57 |
Anonymous (not verified) |
75.162.11.91 |
Iowa Carpentry Construction |
Limited Liability Company |
3000 University Ave 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. |
2022-01-01 |
Martha Marca |
Iowacarpentryconstruction@gmail.com |
Urbandale |
Polk |
Iowa |
Martha Marca |
Carlos Velazquez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Emily Segura |
iowacarpentryconstrucion@gmail.com |
Worker |
West Des Moines |
Polk |
Iowa |
Martha Marca |
Carlos Velazquez |
Signed |
197 |
2020-07-02 09:33 |
Anonymous (not verified) |
66.188.136.150 |
M & EM Trucking |
Proprietorship |
216 4th Ave SE 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. |
(1) I am not electing the employers’ liability coverage. |
2020-07-02 |
Martin Funke |
kschumacher@tricorinsurance.com |
Dyersville |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Funke |
kschumacher@tricorinsurance.com |
Same |
Dyersville |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
1600 |
2023-04-25 14:38 |
Anonymous (not verified) |
94.188.207.223 |
martin garcia |
Proprietorship |
219 austin st sw 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. |
2023-04-25 |
martin garcia ayala |
martingarcia2100@gmail.com |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
martin garcia ayala |
martingarcia2100@gmail.com |
na |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
536 |
2021-06-07 11:01 |
Anonymous (not verified) |
205.221.255.62 |
Mark Lile |
Limited Liability Partnership |
PO Box 36411 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-07 |
Martin Luverne Humphrey Jr |
martinhumphreu@gmail.com |
Des Moines |
Polk |
Iowa |
Jaimi Humphrey |
George Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Lile |
Mark@ultimateautowash.com |
Employer |
Des Moines |
Polk |
Iowa |
Jaimi Humphrey |
George Porter |
Signed |
581 |
2021-07-22 14:29 |
Anonymous (not verified) |
205.221.255.62 |
MartinHumphrey |
Limited Liability Company |
Cummins Rd. Apt 202 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Martin Luverne Humphrey Jr. |
martinhumphreu@gmail.com |
Des Moines |
Polk |
Ioea |
George Porter |
Gerald Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Luverne Humphrey Jr |
martinhumphreu@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
George Porter |
Gerald Lund |
Signed |
103 |
2020-03-25 11:48 |
Anonymous (not verified) |
174.250.52.2 |
ReFormin' Homes |
Proprietorship |
7740 NW 16th Street, 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. |
2020-03-25 |
Martin Samuel Ledy |
reforminhomes@gmail.com |
Ankeny |
Iowa |
United States |
Timothy Allen Raynard |
Nicholas Paul Curtis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Samuel Ledy |
reforminhomes@gmail.com |
Same Person |
Ankeny |
Iowa |
United States |
Timothy Allen Raynard |
Nicholas Paul Curtis |
Signed |
777 |
2021-12-04 10:20 |
Anonymous (not verified) |
107.77.161.58 |
Martinez Painting |
Proprietorship |
3219 bowdoin st desmoines 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. |
2021-12-04 |
Martinez Manuel |
Manuelitogladis29@gmail.com |
Desmoines |
Polk |
Iowa |
Yasco adilovic |
Samir radinovick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martinez Manuel |
Manuelitogladis29@gmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Yasco adilovic |
Samir radinovic |
Signed |
1967 |
2023-12-27 13:28 |
Anonymous (not verified) |
94.188.207.225 |
Marvin Gingrich |
Proprietorship |
114641 Chariot Rd Elgin 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 |
Marvin Gingerich |
darrele@ciains.biz |
Elgin |
Fayette |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Gingerich |
darrele@ciaisn.biz |
Self |
Elgin |
Fayette |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
2130 |
2024-04-02 09:11 |
Anonymous (not verified) |
94.188.207.229 |
Caliz Stone Services LLC |
Limited Liability Company |
1715 E 21st 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. |
2024-04-02 |
Marvin Lopez |
marvincaliz843@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Lopez |
marvincaliz843@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
1918 |
2023-11-21 12:45 |
Anonymous (not verified) |
94.188.205.167 |
515 PAINTING LLC |
Limited Liability Company |
PO Box 157, Berwick, IA 50032 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Marvin Parker |
gcort06@gmail.com |
Berwick |
Polk |
Iowa |
Dillon Parker |
Gary Cort |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Parker |
gcort06@gmail.com |
Owner |
Berwick |
Polk |
Iowa |
Dillon Parket |
Gary Cort |
Signed |
213 |
2020-07-21 17:47 |
Anonymous (not verified) |
107.77.206.41 |
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 |
Mary Kate friess |
mkfriess71@gmail.com |
Fond du lac |
Fond du lac |
WI |
Gordon Lewis |
Ron carpenter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mary Kate friess |
mkfriess71@gmail.com |
Self |
Fond du lac |
Fond du lac |
Wi |
Gordon Lewis |
Ron carpenter |
Signed |
35 |
2020-01-13 13:23 |
Anonymous (not verified) |
173.28.28.57 |
Milkhouse Market, LLC |
Limited Liability Company |
911 Parriott Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-30 |
MARY MEYER |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MARY MEYER |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1014 |
2022-03-28 16:33 |
Anonymous (not verified) |
76.102.203.170 |
Self - Maryssa Wanlass |
Proprietorship |
871 Wood St. Oakland CA 94607 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Maryssa Wanlass |
maryssa.wanlass@alli-center.com |
Oakland |
Alameda |
California |
Mark Vashro |
Don Naughton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maryssa Wanlass |
maryssa.wanlass@alli-center.com |
Self |
Oakland |
Alameda |
California |
Mark Vashro |
Don Naughton |
Signed |
450 |
2021-03-25 11:59 |
Anonymous (not verified) |
66.188.136.150 |
Mason Cook |
Proprietorship |
10604 Bradford Road, Indianapolis, IN 46231 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-23 |
Mason Cook |
kschumacher@tricorinsurance.com |
Indianapolis |
Marion |
IN |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Cook |
kschumacher@tricorinsurance.com |
Same |
Indianapolis |
Marion |
IN |
Russell Masartis |
Shuree Behr |
Signed |
942 |
2022-03-02 18:52 |
Anonymous (not verified) |
173.16.196.70 |
Mason Cooper |
Limited Liability Company |
4213 Southwest 23rd Place |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-02 |
Mason Cooper |
koupenc5@icloud.com |
Des Moines |
Polk |
IA |
Savannah Cooper |
Norman Weathers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Cooper |
koupenc5@icloud.com |
Myself |
Des Moines |
Polk |
IA |
Savannah Cooper |
Norman Weathers |
Signed |
1878 |
2023-10-26 09:06 |
Anonymous (not verified) |
94.188.205.168 |
Jones Facility Maintenance |
Limited Liability Company |
3929 Council 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. |
2023-10-25 |
Mason Jones |
jonesmason546@gmail.com |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Bradley Jones |
jonesmason546@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
330 |
2020-12-03 08:11 |
Anonymous (not verified) |
208.126.61.46 |
Hometown Comfort Heating & Cooling, LLC. |
Limited Liability Company |
1855 280th St. Webster City, Ia. 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-03 |
Mason Ormesher |
hometowncomfortia@gmail.com |
Webster City |
IA |
United States |
Kylee Ormesher |
Karen Ostrem |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Ormesher |
hometowncomfortia@gmail.com |
Owner |
Webster City |
Hamilton |
Iowa |
Kylee Ormesher |
Karen Ostem |
Signed |
2012 |
2024-01-31 10:38 |
Anonymous (not verified) |
94.188.207.228 |
Mathew Soulis |
Proprietorship |
618 Boston Drive, 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. |
2023-01-31 |
Mathew Soulis |
mathew.soulis@gmail.com |
Davenport |
Scott |
IA |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
JNisiewicz@leafhome.com |
Recruiter |
Kansas City |
Johnson |
MO |
Cody Dunbar |
Monica Acosta |
Signed |
514 |
2021-05-11 13:16 |
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 |
MATT CACEK |
MATT@RUTHVENROCKS.COM |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATT CACEK |
joel@walkerinsuranceia.com |
MEMBER |
MILFORD |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1717 |
2023-06-29 11:42 |
Anonymous (not verified) |
94.188.205.169 |
POWDER COATING CENTER |
Limited Liability Company |
61 3RD ST NE 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. |
2023-06-28 |
MATT EMBREY |
MSEMBREY21@GMAIL.COM |
HARTLEY |
OBRIEN |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATT EMBREY |
MSEMBREY21@GMAIL.COM |
OWNER |
HARTLEY |
OBRIEN |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
1765 |
2023-07-27 14:27 |
Anonymous (not verified) |
94.188.207.225 |
Midwest Systems |
Proprietorship |
2877 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. |
2023-07-27 |
Matt Griswold |
midwestsystems@live.com |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Griswold |
midwestsystems@live.com |
Owner |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
55 |
2020-02-07 15:14 |
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 |
Matt Johnson |
mattjohnson7555@gmail.com |
Jackson TWP |
Butler |
Iowa |
Ty Burke |
Lori Frerichs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tylor Burke |
tburke@acceladvantage.com |
Agent |
Waverly |
IA |
United States |
Tony Pollastrini |
Lori Frerichs |
Signed |
1567 |
2023-04-12 10:01 |
Anonymous (not verified) |
94.188.205.177 |
Hearts on fire llc |
Limited Liability Partnership |
931 14th Ave Se Altoona Iowa 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-12 |
Matt Moffet |
dsm@fibrenew.com |
Altoona |
Polk |
Iowa |
Jason McDowell |
Mike Wennekamp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Moffet |
dam@fibrenew.com |
Owner |
Altoona |
Polk |
Iowa |
Jason McDowell |
Mike Wennekamp |
Signed |
15 |
2019-12-30 18:13 |
Anonymous (not verified) |
104.166.243.52 |
Matt Moore |
Proprietorship |
8450 Hickman Road #15C |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-30 |
Matt Moore |
mljm2016@outlook.com |
Clive |
Iowa |
Iowa |
Tom Onnen |
James Buffington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Moore |
mljm2016@outlook.com |
Subcontractor |
Urbandale |
IOWA |
United States |
Tom Onnen |
James Buffington |
Signed |
1335 |
2022-10-17 11:32 |
Anonymous (not verified) |
71.39.227.238 |
PELZER AG LLC |
Limited Liability Company |
16864 280TH 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. |
2022-10-17 |
MATT PELZER |
MPELZERFARMS@GMAIL.COM |
REDFIELD |
DALLAS |
IOWA |
ABBEY LUELLEN |
DON RICHARDSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATT PELZER |
MPELZERFARMS@GMAIL.COM |
PRESIDENT |
REDFIELD |
DALLAS |
IOWA |
ABBEY LUELLEN |
DON RICHARDSON |
Signed |
377 |
2021-01-26 13:31 |
Anonymous (not verified) |
184.63.6.1 |
Matt Reynolds |
Proprietorship |
684 Cedar Valley 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. |
2021-01-26 |
Matt Reynolds |
matt.reynolds0891@gmail.com |
Tipton |
Cedar |
Iowa |
Anna Miller |
Steve Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Reynolds |
matt.reynolds0891@gmail.com |
Proprietorship |
Tipton |
Cedar |
Iowa |
Anna Miller |
Steve Miller |
Signed |
1768 |
2023-07-29 11:10 |
Anonymous (not verified) |
94.188.207.223 |
Makana Industries LLC |
Limited Liability Company |
1800 Grand Ave #352, 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. |
2023-07-29 |
Matthew Akana |
mandiremod515@gmail.com |
West Des Moines |
Polk |
Iowa |
Catherine Sobrado |
James Fowler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rocket Lawyer Corporate Services LLC |
mandiremod515@gmail.com |
Registered agent |
Des Moines |
Polk |
Iowa |
Catherine Sobrado |
James Fowler |
Signed |
1463 |
2023-02-17 14:24 |
Anonymous (not verified) |
94.188.207.224 |
Matt Evans |
Limited Liability Company |
508 53rd Place 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. |
2023-02-17 |
Matthew Evans |
matt@bigroofing515.com |
West Des Moines |
Polk |
Iowa |
Steve Bieghler |
Matt Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Evans |
matt@bigroofing515.com |
Self |
West Des Moines |
Polk |
Iowa |
Steve Bieghler |
Matt Evans |
Signed |
1051 |
2022-04-14 17:56 |
Anonymous (not verified) |
199.59.236.46 |
Triple M Welding |
Proprietorship |
407 4th St 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. |
2022-04-14 |
Matthew Gibson |
matthew.gibson02003@gmail.com |
Independence |
Iowa |
Iowa |
Brandon Keener |
Cody Laughlin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Gibson |
matthew.gibson02003@gmail.com |
Owner |
Independence |
Iowa |
Iowa |
Brandon Keener |
Cody Laughlin |
Signed |
158 |
2020-05-18 13:58 |
Anonymous (not verified) |
108.59.100.21 |
LNM Truck & Trailer Repair LLC |
Limited Liability Company |
902 Rossville Rd, Waukon, IA 52172 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-05-18 |
Matthew Hawkins |
lnmtruckandtrailerrepair@gmail.com |
Waterville |
Allamakee |
IA |
Jane M Regan |
Chelsea Whalen |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Matthew Hawkins |
lnmtruckandtrailerrepair@gmail.com |
Owner |
Waterville |
Allamakee |
IA |
Jane M Regan |
Chelsea Whalen |
Signed |
1897 |
2023-11-06 09:12 |
Anonymous (not verified) |
94.188.205.177 |
Matthew Jones |
Limited Liability Company |
124 NE 49th 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. |
2023-11-06 |
Matthew Jones |
mjj4242@gmail.com |
Ankeny |
Polk |
IA |
Duan Willform |
AJ Giebelstein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Jones |
mjj4242@gmail.com |
Self |
Ankeny |
Polk |
IA |
AJ Giebelstein |
Duan Willform |
Signed |
159 |
2020-05-18 14:21 |
Anonymous (not verified) |
173.28.28.57 |
Matthew Klahsen |
Proprietorship |
1103 Gray 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. |
2020-05-12 |
Matthew Klahsen |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Klahsen |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1782 |
2023-08-04 08:04 |
Anonymous (not verified) |
94.188.207.229 |
Matt Larson Construction |
Limited Liability Company |
1208 Hazel St. 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. |
2023-08-04 |
Matthew Mark Larson |
larson-m@hotmail.com |
Pella |
Marion |
IA |
Brian Huddle |
Jon E. Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jon E. Miller |
stmarypella@iowatelecom.net |
Parish Secretary |
Pella |
IOWA |
United States |
Brian Huddle |
Jon E. Miller |
Signed |
409 |
2021-02-18 16:35 |
Anonymous (not verified) |
173.31.147.225 |
MATTHEW MYHRE DBA GUNS GALORE |
Proprietorship |
2329 220TH 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. |
2021-02-18 |
MATTHEW MYHRE |
MYHRE3063@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATTHEW MYHRE DBA GUNS GALORE |
MYHRE3063@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
764 |
2021-11-22 15:33 |
Anonymous (not verified) |
198.14.219.227 |
Central Iowa Painting and Contracting LLC |
Limited Liability Company |
408 Freel Drive, Ste. 101, 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. |
2021-11-22 |
Matthew Paul Klucas |
mklucas50@gmail.com |
Fort Dodge |
Webster County |
Iowa |
Jordan Watkins |
Scott Schuler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Klucas |
mklucas50@gmail.com |
Owner of Buisness |
Fort Dodge |
Webster County |
Iowa |
Jordan Watkins |
Scott Schuler |
Signed |
119 |
2020-04-14 14:38 |
Anonymous (not verified) |
66.188.136.150 |
Matthew Popejoy |
Proprietorship |
7897 21st Ave., Blaristown, IA 52209 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Matthew Popejoy |
popejoymatthew@gmail.com |
Blairstown |
Benton |
IA |
Russell Masartis |
Cody McClain |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Oberfoell |
doberfoell@tricorinsurance.com |
Agent |
Blairstown |
Benton |
IA |
Russell Masartis |
Cody McClain |
Signed |
1880 |
2023-10-26 13:24 |
Anonymous (not verified) |
94.188.205.167 |
Brown Remodel & Construction LLC |
Limited Liability Company |
7819 Evans St Mingo iowa 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. |
2023-10-26 |
Matthew Ray Brown |
brownremodel@gmail.com |
Mingo |
Jasper |
Iowa |
Rebecca Lynn Brown |
Michael Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Ray Brown |
brownremodel@gmail.com |
Self |
Mingo |
Jasper |
Iowa |
Rebecca lynn Brown |
Michael Moore |
Signed |
534 |
2021-06-04 12:47 |
Anonymous (not verified) |
192.119.129.187 |
KMA Communications, LLC |
Limited Liability Company |
435 croston rd. Stockport, OH 43787 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-04 |
Matthew Razen Alsup |
malsupbrgi@gmail.com |
Stockport |
Morgan |
Ohio |
Stephen Alsup |
Nancy Alsup |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Razen Alsup |
malsupbrgi@gmail.com |
Same person |
Stockport |
Morgan |
Ohio |
Stephen Alsup |
Nancy Alsup |
Signed |
858 |
2022-01-27 08:06 |
Anonymous (not verified) |
75.162.81.119 |
MR Custom Tile & Flooring LLC |
Limited Liability Company |
14390 Newbold 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. |
2022-01-27 |
Matthew Royer |
royer20@yahoo.com |
Indianola |
Warren |
United States |
Leiloni Royer |
Elena Royer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Royer |
royer20@yahoo.com |
Myself |
Indianola |
Warren |
United States |
Leiloni Royer |
Elena Royer |
Signed |
156 |
2020-05-13 20:37 |
Anonymous (not verified) |
216.106.236.82 |
MR Electric LLC |
Limited Liability Company |
1853 230st 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. |
2020-05-13 |
Matthew Rozeboom |
matt.rozeboom@gmail.com |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Rozeboom |
matt.rozeboom@gmail.com |
Owner/President |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
853 |
2022-01-24 08:45 |
Anonymous (not verified) |
173.27.193.218 |
Matt ruble |
Limited Liability Company |
808 Grandview 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. |
2022-01-23 |
Matthew ruble |
gmddetailing2012@gmail.com |
Des Moines |
Polk |
Iowa |
Matt Ruble |
Matt Ruble |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Ruble |
gmddetailing2012@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Matt Ruble |
Matt Ruble |
Signed |
840 |
2022-01-14 10:58 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Matthew Shear |
mshear@midwestsolarservices.com |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
841 |
2022-01-14 15:23 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Matthew Shear |
mshear@midwestsolarservices.com |
Hanover |
Jo Daviess |
IL |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
1238 |
2022-08-02 10:24 |
Anonymous (not verified) |
70.96.153.153 |
Matthew Smith |
Proprietorship |
2070 Golfview Ct, 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. |
2022-08-02 |
Matthew Smith |
matt.s@optionsexteriors.com |
Marion |
Linn |
Iowa |
Charlotte Rasmussen |
Aus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Smith |
matt.s@optionsexteriors.com |
Self/Owner |
Marion |
Linn |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
2081 |
2024-03-08 10:44 |
Anonymous (not verified) |
94.188.205.167 |
T & S Sandblasting and Painting LLC |
Limited Liability Company |
101 Clinton ST Corwith IA 50430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Matthew Tindall |
matt.tindall83@gmail.com |
Corwith |
Hancock |
IA |
Wendy S Jensen |
Jason Bradley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Tindall |
matt.tindall83@gmail.com |
self |
Corwith |
Hancock |
IA |
Wendy S Jensen |
Jason Bradley |
Signed |
619 |
2021-08-25 14:31 |
Anonymous (not verified) |
192.154.15.2 |
MAV Restorations LLC |
Limited Liability Company |
5461 Meadow Ct, Asbury, IA 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-25 |
Matthew Vaske |
mlvaske@gmail.com |
Asbury |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Vaske |
mlvaske@gmail.com |
Self |
Asbury |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
663 |
2021-10-04 09:45 |
Anonymous (not verified) |
166.181.80.1 |
Matthew Winters |
Proprietorship |
9220 Summit 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. |
2021-10-04 |
Matthew Winters |
mattwinters55@gmail.com |
Johnston |
Polk |
Iowa |
Brittany Strub |
Judy Sansom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Winters |
mattwinters55@gmail.com |
Self |
Johnston |
Polk |
Iowa |
Brittany Strub |
Judy Sansom |
Signed |
1178 |
2022-07-05 12:02 |
Anonymous (not verified) |
172.58.122.51 |
Wright home restoration |
Limited Liability Company |
2914 South Union 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. |
2022-07-05 |
Matthew Wright |
wright.home.restoration@gmail.com |
Des Moines |
IA |
United States |
Jane wright |
Robert wright |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wright home restoration |
wright.home.restoration@gmail.com |
Myself |
Des Moines |
IA |
United States |
Jane wright |
Robert Wright |
Signed |
1702 |
2023-06-22 22:57 |
Anonymous (not verified) |
94.188.207.230 |
A&M Consulting LLC |
Limited Liability Company |
1208 5th Ave, North Humboldt Iowa, 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. |
2023-06-22 |
maureen Waweru |
maureenrealtyaz@yahoo.com |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
maureen Waweru |
maureenrealtyaz@yahoo.com |
Self |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
109 |
2020-04-03 12:42 |
Anonymous (not verified) |
174.219.131.25 |
Upright Construction |
Limited Liability Company |
2514 S norton ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-03 |
Maurice Williams |
uprightway@mail.com |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maurice Williams |
uprightway@mail.com |
Owner |
Sioux Falls |
Minihaha |
SD |
Ashley Williams |
Chris Johnson |
Signed |
2126 |
2024-03-29 09:35 |
Anonymous (not verified) |
94.188.207.227 |
MPO Masonry |
Proprietorship |
5027 s 20th at apt 12 Omaha ne 68107 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Mauricio Ortega |
pallaresmauricio72@gmail.com |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mauricio Ortega |
pallaresmauricio72@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Drake Rapaich |
Sunita Rapaich |
Signed |
1910 |
2023-11-15 13:06 |
Anonymous (not verified) |
94.188.207.228 |
RODRIGUEZ ENTERPRISES III INC |
Limited Liability Company |
905 W US HIGHWAY 30 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. |
2023-11-14 |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
CARROLL |
CARROLL |
IOWA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
OWNER |
CARROLL |
CARROLL |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
897 |
2022-02-04 15:15 |
Anonymous (not verified) |
163.116.133.119 |
Schauf Investments LLC |
Limited Liability Company |
3465 Vermont Street, New Virginia, 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. |
2022-02-04 |
Maxwell Schauf |
max.schauf@gmail.com |
New Virginia |
IA |
United States |
Krisha Schauf |
Robin Schauf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maxwell Schauf |
max.schauf@gmail.com |
General Member |
New Virginia |
IA |
United States |
Krisha Schauf |
Robin Schauf |
Signed |
574 |
2021-07-14 10:43 |
Anonymous (not verified) |
173.27.17.202 |
Maxwell Taylor |
Proprietorship |
618 east Colorado St. Davenport Iowa 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. |
2021-07-14 |
Maxwell Taylor |
maxwelltaylor33@icloud.com |
Davenport |
Scott |
Iowa |
Jacob Nagel |
Ty Reindl |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maxwell Taylor |
maxwelltaylor33@icloud.com |
Self |
Davenport |
Scott |
Iowa |
Jacob Nagel |
Ty Reindl |
Signed |
563 |
2021-07-08 12:16 |
Anonymous (not verified) |
173.17.250.209 |
Forest Avenue Outreach |
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. |
2021-07-08 |
Maya Bromolson |
maya@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 |
335 |
2020-12-08 11:08 |
Anonymous (not verified) |
173.18.16.129 |
quintanillas construction llc |
Limited Liability Company |
3136 6th ave des moines ia 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-08 |
maynor quintanilla |
maynorquintanilla42@gmail.com |
des moines |
polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
maynor quintanilla |
maynorquintanilla42@gmail.com |
owner |
des moines |
polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
1971 |
2023-12-29 19:27 |
Anonymous (not verified) |
94.188.207.223 |
Megan Thibodeau |
Proprietorship |
4301 Adams 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. |
2023-12-29 |
Megan E Thibodeau |
megancallan@hotmail.com |
Des Moines |
Iowa |
United States |
Travis Releford |
Courtney Releford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan E Thibodeau |
megancallan@hotmail.com |
Self |
Des Moines |
Iowa |
United States |
Travis Releford |
Courtney Releford |
Signed |
137 |
2020-04-28 10:08 |
Anonymous (not verified) |
74.84.101.138 |
Nisse Preschool & Kids Place |
Partnership |
311 College Drive 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. |
2020-02-26 |
Megan Sherman |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan Sherman |
chelsea.whalen@upperiowains.com |
President |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
911 |
2022-02-11 19:58 |
Anonymous (not verified) |
166.181.81.90 |
Legacy Taxi |
Limited Liability Company |
2006 E Lincoln Way Suite 2 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. |
2022-02-11 |
Megan Zogg |
sctlegacy@gmail.com |
Boone |
Boone |
IA |
Jerri Ecord |
Sharon Iron |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Legacy Taxi |
sctlegacy@gmail.com |
Owner |
Boone |
Boone |
IA |
Jerri Ecord |
Sharon Iron |
Signed |
1884 |
2023-10-27 18:32 |
Anonymous (not verified) |
94.188.205.177 |
J&M dry wall |
Proprietorship |
948 Kern 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. |
2023-10-27 |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Waterloo |
Black hawk |
IA |
Luis flores |
Luis flores |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Self |
Waterloo |
Black hawk |
IA |
Luis Flores |
Luis flores |
Signed |
530 |
2021-05-25 08:30 |
Anonymous (not verified) |
159.242.43.24 |
FoxTrot Foods, LLC |
Limited Liability Company |
13-15 S Federal 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. |
2021-05-25 |
Melissa Fabian |
melissafabian@yahoo.com |
Mason City |
Cerro Gordo |
Iowa |
Jenny McIntyre |
Dan Wunschel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Fabian |
melissafabian@yahoo.com |
Owner-Member |
Mason City |
Cerro Gordo |
Iowa |
Jenny McIntyre |
Dan Wunschel |
Signed |
2172 |
2024-04-22 14:09 |
Anonymous (not verified) |
94.188.205.167 |
Melissa J Madison |
Proprietorship |
326 NE Olivewood 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. |
2024-04-22 |
Melissa Janelle Madison |
melissamadison01@gmail.com |
Waukee |
DALLAS |
IOWA |
Haley Sears |
Scott Leinen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Madison |
melissamadison01@gmail.com |
myself |
Waukee |
Dallas |
Iowa |
Haley Sears |
Scott Leinen |
Signed |
668 |
2021-10-12 16:11 |
Anonymous (not verified) |
173.18.22.217 |
Mo's Cleaning LLC |
Limited Liability Company |
1412 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. |
2021-10-12 |
Melissa Jones |
commcleanwithme123@gmail.com |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Jones |
commcleanwithme123@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
363 |
2021-01-14 12:17 |
Anonymous (not verified) |
173.26.157.255 |
Shear Bliss Pet Salon |
Limited Liability Company |
824 Ansborough Ave. 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. |
2021-01-14 |
Melissa Kay Herold |
shearblisspet@aol.com |
Cedar Falls |
Black Hawk |
Iowa |
Janice Rae Bebee |
Danny J Bebee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meliss Kay Herold |
shearblisspet@aol.com |
self |
Cedar Falls |
Black Hawk |
Iowa |
Janice Rae Bebee |
Danny J Bebee |
Signed |
1621 |
2023-05-01 15:53 |
Anonymous (not verified) |
94.188.207.226 |
Hearing Health Care |
Limited Liability Partnership |
2519 S 16TH 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. |
2023-05-01 |
Melissa Knoell |
MELISSAKNOELL@YAHOO.COM |
COUNCIL BLFS |
IA |
IA |
Bruce Carol Johnk |
Marcelyn Maureen Johnk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Knoell |
melissaknoell@yahoo.com |
self |
Council Bluffs |
Pottawattomi |
IA |
Bruce Carol Johnk |
Marcelyn Maureen Johnk |
Signed |
1094 |
2022-05-12 09:26 |
Anonymous (not verified) |
173.30.136.186 |
Missy Weber |
Limited Liability Company |
4290 Spring Creek Road Jesup, Iowa 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. |
2022-05-12 |
Melissa Weber |
mweber@cardinalcapital.us |
JESUP |
Black Hawk |
Iowa |
Sharon Woodson |
Shelly Donlon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Weber |
mweber@cardinalcapital.us |
partner/husband |
Jesup |
Blackhawk |
Iowa |
Janice Weber |
Laverne Weber |
Signed |
1729 |
2023-07-09 15:33 |
Anonymous (not verified) |
94.188.207.223 |
Melvin A mineros |
Limited Liability Company |
6209 Windsor dr 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. |
2023-07-09 |
Melvin A mineros |
minerosframing.llc@gmail.com |
Des moines |
Polk |
IA |
Orlando dominguez |
Isaac salazar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaime leiva |
jaime@boersmaninsurance.com |
Agent |
Des moines |
Polk |
IA |
Narciso hidalgo |
Balmore perez |
Signed |
1778 |
2023-08-03 14:52 |
Anonymous (not verified) |
94.188.207.227 |
Melvin A mineros |
Limited Liability Company |
6209 Windsor dr 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2023-06-22 |
Melvin alexander mineros |
minerosframing.llc@gmail.com |
Des moines |
Polk |
IA |
Orlando dominguez |
Isaac salazar |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jaime leiva |
jaime@boersmaninsurance.com |
Agent |
Des moines |
Polk |
IA |
Narciso hidalgo |
Balmore perez |
Signed |
615 |
2021-08-20 16:22 |
Anonymous (not verified) |
50.81.152.147 |
CPIA Home Specialists LLC |
Limited Liability Company |
1214 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. |
2021-08-20 |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Benitez |
Benitezmelvin0@gmail.com |
Owner |
Des Moines |
Iowa |
United States |
Salvador Benitez |
Zoila Benitez |
Signed |
2197 |
2024-05-02 09:30 |
Anonymous (not verified) |
94.188.207.229 |
Melvin Osorio |
Proprietorship |
3848 E 14th St Trlr 78, 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. |
2024-05-02 |
Melvin Osorio |
matamorosana56@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Osorio |
matamorosana56@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
1660 |
2023-05-24 10:11 |
Anonymous (not verified) |
94.188.205.177 |
Might Lawn Care |
Limited Liability Company |
1920 W 70th 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. |
2023-05-24 |
Meredith Whitney Might |
mightlawncare@gmail.com |
Davenport |
Scott |
IA |
Samuel Lawrence Might |
Suzette Henriksen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meredith Might |
mightlawncare@gmail.com |
Owner |
Davenport |
Scott |
IA |
Samuel Lawrence Might |
Suzette Henriksen |
Signed |
920 |
2022-02-17 10:15 |
Anonymous (not verified) |
208.81.192.69 |
Wapsie Valley Construction, LLC |
Limited Liability Company |
1154 Dennison Avenue, 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 |
Merle B. 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 B. Miller |
accounting@robertseddy.com |
Same person |
Fairbank |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
1313 |
2022-09-19 11:03 |
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. |
2022-09-19 |
Merle Broihier |
premiere_pd_llc@yahoo.com |
Bettendorf |
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 |
209 |
2020-07-19 17:02 |
Anonymous (not verified) |
173.189.166.183 |
Merle Fox |
Proprietorship |
314 N Jackson St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-19 |
Merle T Fox |
merletravisfox.79@gmail.com |
Lisbon |
Linn |
Iowa |
Dustin Ohlfest |
Chelsea Brown |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Merle Fox |
merletravisfox.79@gmail.com |
self |
Lisbon |
Linn |
Iowa |
Dustin Ohlfest |
Chelsea Brown |
Signed |
2021 |
2024-02-02 10:12 |
Anonymous (not verified) |
94.188.207.227 |
JUSIC ENTERPRISES LLC DBA MJS TREE SERVICE |
Limited Liability Company |
11619 NW 106TH AVE 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. |
2024-02-02 |
MERSUDIN JUSIC |
MERSO.JUSIC@GMAIL.COM |
GRANGER |
POLK COUNTY |
IOWA |
RICHARD BALES |
ZACHARY SMITH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MERSUDIN JUSIC |
MERSO.JUSIC@GMAIL.COM |
MEMBER OWNER |
GRANGER |
POLK |
IOWA |
RICH BALES |
ZACHARY SMITH |
Signed |
1895 |
2023-11-03 12:21 |
Anonymous (not verified) |
94.188.207.227 |
Oxbo LLC |
Limited Liability Company |
2528 Evergreen Ave. Red Oak, IA 51566 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Mettra Sperling |
sperlingrose66@gmail.com |
Red Oak |
Montgomery |
IA |
Chantal Sperling |
Derek Penry |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mettra Sperling |
sperlingrose66@gmail.com |
Self |
Red Oak |
Montgomery |
IA |
Chantal Sperling |
Derek Penry |
Signed |
1835 |
2023-09-09 15:11 |
Anonymous (not verified) |
94.188.207.224 |
Heartland Ultrasonography Group |
Limited Liability Company |
1015 Woodland Dr 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. |
2023-09-09 |
Micah Ezra Wiele |
mewiele99@gmail.com |
Ankeny |
Polk |
Iowa |
Nathan Miguel Diaz |
Brandon Allen Pemoulie |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Micah Ezra Wiele |
heartlandusgroup@outlook.com |
Co-owner |
Ankeny |
Polk |
Iowa |
Nathan Miguel Diaz |
Brandon Allen Pemoulie |
Signed |
1478 |
2023-02-23 13:25 |
Anonymous (not verified) |
94.188.207.230 |
Achenbach Renovations and Flooring |
Proprietorship |
PO Box 234 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Michael Achenbach |
constructiowa.ma@gmail.com |
Adair |
Iowa |
United States |
Michael Achenbach |
Michael Achenbach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Achenbach |
constructiowa.ma@gmail.com |
Owner |
Adair |
Iowa |
United States |
Michael Achenbach |
Michael Achenbach |
Signed |
626 |
2021-08-31 11:39 |
Anonymous (not verified) |
166.181.81.253 |
Birds landscape maintenance LLC |
Limited Liability Company |
1307 w 4th st 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. |
2021-08-31 |
Michael Alan bird |
birdslawn@hotmail.com |
Newton |
Jasper |
Iowa |
Jeff Dennis carder |
Dustin James bos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Alan bird |
birdslawn@hotmail.com |
Same - owner |
Newton |
Jasper |
Iowa |
Jeff Dennis carder |
Dustin James bos |
Signed |
862 |
2022-01-27 12:02 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction,LLC |
Limited Liability Company |
4508 Hiawatha Ave NE Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Michael Allen Becker |
mike4bbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Brother/partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
927 |
2022-02-17 16:22 |
Anonymous (not verified) |
174.215.244.78 |
Mike Benson dba Standard Drywall |
Proprietorship |
1713 w7th st. 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. |
2022-02-17 |
Michael Arlyn Benson |
mikekimbenson@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Leesa Marie Wheeler |
Austin Michael Thorpe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Arlyn Benson |
mikekimbenson@gmail.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Leesa Marie Wheeler |
Austin Michael Thorpe |
Signed |
236 |
2020-08-18 16:15 |
Anonymous (not verified) |
173.28.28.57 |
Michael Ballhagen |
Proprietorship |
279 Pine Street, 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. |
2020-08-07 |
Michael Ballhagen |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Ballhagen |
cmins_re@mchsi.com |
Self |
Allison |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1217 |
2022-07-21 06:51 |
Anonymous (not verified) |
209.152.88.53 |
Bullard Accounting Services, LLC |
Limited Liability Company |
4519 Scouts View Dr, 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. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
Michael Bullard |
mikeandkarenbullard@gmail.com |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Bullard |
mikeandkarenbullard@gmail.com |
President of Company |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
665 |
2021-10-06 09:22 |
Anonymous (not verified) |
192.96.173.171 |
Michael Childers |
Proprietorship |
21 N.6th street savanna 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. |
2021-10-06 |
Michael Childers |
peddler73@hotmail.com |
Savanna |
Carroll |
Illinois |
Brandy arnold |
Jordan nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas city |
Clay |
Mo |
Jordan nisiewicz |
Brandy arnold |
Signed |
275 |
2020-10-08 11:56 |
Anonymous (not verified) |
166.224.213.71 |
Michael corcoran |
Proprietorship |
311 e elm 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. |
2020-10-07 |
Michael corcoran |
mikecorcoran1990@gmail.com |
West Union |
Fayette |
IA |
Heather corcoran |
Chris Fels |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael corcoran |
mikecorcoran1990@gmail.com |
Self |
West Union |
Fayette |
IA |
Heather corcoran |
Chris fels |
Signed |
1972 |
2024-01-02 14:19 |
Anonymous (not verified) |
94.188.205.174 |
Parker Trucking LLC |
Limited Liability Company |
1507 Greene Street 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. |
2024-01-02 |
Michael Craig Parker |
mcparker31@msn.com |
Adel |
Dallas |
Iowa |
Jessie Rynearson |
Melisha Rynearson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Parker |
mcparker31@msn.com |
Owner/Memeber |
Adel |
Dallas |
IA |
Jessie Rynearson |
Melishia Rynearson |
Signed |
2108 |
2024-03-20 12:51 |
Anonymous (not verified) |
94.188.207.230 |
Mc Storm Restortion Services |
Limited Liability Company |
1913 NE LITTLE BEAVER 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. |
2024-03-20 |
Michael Cross |
crossmichael1@hotmail.com |
Grimes |
IA |
United States |
Courtney Lesher |
Chandler Steffy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Cross |
crossmichael1@hotmail.com |
owner |
Grimes |
IA |
United States |
Courtney Lesher |
Chandler Steffy |
Signed |
895 |
2022-02-04 11:57 |
Anonymous (not verified) |
216.189.133.155 |
A1A Sandblasting (Iowa) |
Proprietorship |
334 main street S.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. |
2020-02-04 |
michael d marjama |
mike.orie@yahoo.com |
menahga |
MN |
United States |
Josh Louviere |
Kevin Tomperi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
michael d marjama |
mike.orie@yahoo.com |
Owner |
menahga |
MN |
United States |
Josh Louviere |
Kevin Tomperi |
Signed |
317 |
2020-11-15 19:20 |
Anonymous (not verified) |
172.58.83.192 |
All Cut Lawn Care |
Proprietorship |
3506 Glover 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. |
2020-11-15 |
Michael D Money |
michaelmoney883@gmail.com |
Des Moines |
Polk |
Iowa |
Deanna L Phagan |
Diana J Jennings |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael D Money |
michaelmoney883@gmail.com |
Myself |
Des Moines |
Polk |
Iowa |
Deanna L Phagan |
Diana J Jennings |
Signed |
1707 |
2023-06-25 10:39 |
Anonymous (not verified) |
94.188.207.224 |
Michael D Ray |
Proprietorship |
4944 Holcomb 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. |
2023-06-22 |
Michael D Ray Jr |
mdray01@msn.com |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael D Ray |
mdray01@msn.com |
Owner Proprietor |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
1698 |
2023-06-20 16:43 |
Anonymous (not verified) |
94.188.205.167 |
Mike farrell |
Proprietorship |
306 ne trilein 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. |
2023-06-20 |
Michael David farrell |
farrellsfmr@yahoo.com |
Ankeny |
Polk |
Ia |
ERICK SCHULST |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael David farrell |
farrellsfmr@yahoo.com |
Owner |
Ankeny |
Polk |
Iowa |
Erick Schuldr |
Kelly .Coluzzi3 |
Signed |
809 |
2021-12-21 14:42 |
Anonymous (not verified) |
75.162.173.166 |
Mike Money |
Proprietorship |
3506 Glover 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. |
2021-12-21 |
Michael David Money |
poojennings78@gmail.com |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Steve Jennings |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael David Money |
poojennings78@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Steve Jennings |
Signed |
2083 |
2024-03-08 14:41 |
Anonymous (not verified) |
94.188.205.169 |
Michael Dwayne Wahl Jr DBA Dents Etc |
Proprietorship |
3458 Highway 65/69, 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. |
2024-03-08 |
Michael Dwayne Wahl Jr |
darrin@fisherbodypaint.com |
Carlisle |
Polk |
Iowa |
Darrin Morrison |
Anthony Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Schreck |
mark.schreck@insurancestationinc.com |
Agent |
Altoona |
IA |
IA |
Darrin Morrison |
Anthony Garcia |
Signed |
129 |
2020-04-24 15:28 |
Anonymous (not verified) |
173.28.28.57 |
Michael Jansen |
Proprietorship |
108 6th Street, Parkersburg, 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. |
2020-04-10 |
Michael G Jansen |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael G Jansen |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
290 |
2020-10-23 15:13 |
Anonymous (not verified) |
74.42.24.42 |
Gunter Trucking LLC |
Limited Liability Company |
704 River Ave N., Belmond, IA 50421 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-23 |
Michael James Gunter |
mikegunter885@yahoo.com |
Belmond |
Wright |
Iowa |
Sondra Faye Godsell |
Lori Lynn Studer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael James Gunter |
mikegunter885@yahoo.com |
Owner |
Belmond |
Wright |
Iowa |
Sondra Faye Godsell |
Lori Lynn Studer |
Signed |
1475 |
2023-02-21 18:42 |
Anonymous (not verified) |
94.188.207.230 |
Michael Goodyk Consgtruction |
Proprietorship |
2392 Keokuk Drive Pella, Iowa. 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. |
2023-02-20 |
Michael Jay Goodyk |
mikegoodyk@gmail.com |
Pella |
Marion |
Iowa |
Joy Ekloffe |
Rick Ekloffe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gorp Edwards insurance |
bwilliams@vangorpins.com |
Insurance Agent |
Pella |
Marion |
Iowa |
Joy Ekloffe |
Rick Ekloffe |
Signed |
96 |
2020-03-19 12:11 |
Anonymous (not verified) |
173.24.181.211 |
JENSEN GROUP LP |
Limited Liability Partnership |
PO BOX 721 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. |
2020-03-18 |
MICHAEL JENSEN |
Michael@BuyGreatLakes.com |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MICHAEL JENSEN |
JOEL@WALKERINSURANCE.COM |
PARTNER |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
2007 |
2024-01-29 13:13 |
Anonymous (not verified) |
94.188.205.174 |
Saratoga Seamless Gutters LLC |
Limited Liability Company |
10328 Howard Ave, Lime Springs, IA 52155 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-29 |
Michael Langlais |
saratogaseamlessgutters@gmail.com |
Lime Springs |
Howard |
IA |
Amanda Doty |
Michaela Langlais |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Langlais |
saratogaseamlessgutters@gmail.com |
Owner |
Lime Springs |
Howard |
IA |
Amanda Doty |
Michaela Langlais |
Signed |
281 |
2020-10-20 08:58 |
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. |
2020-10-20 |
Michael Lee Baer |
lbaer@mergemidwest.com |
Louisburg |
Miami |
Kansas |
Heather Lee Baer |
Ami Bowes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Janelle Marie Clayton |
jclayton@mergemidwest.com |
Self |
Olathe |
Johnson |
Kansas |
Patrick McCartney |
David Jahner |
Signed |
816 |
2021-12-30 09:56 |
Anonymous (not verified) |
174.199.83.133 |
Michael Fales |
Proprietorship |
1987 180th 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. |
2021-12-30 |
Michael Lee Fales |
Chubby__69@hotmail.com |
Canby |
Yellow Medicine |
Minnesota |
Tori Fales |
Jean Fales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Lee Fales |
Chubby__69@hotmail.com |
Owner |
Canby |
Yellow Medicine |
Minnesota |
Tori Fales |
Jean Fales |
Signed |
371 |
2021-01-22 14:25 |
Anonymous (not verified) |
71.39.227.238 |
Michael McClure |
Proprietorship |
2553 240th 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. |
2021-01-22 |
Michael McClure |
mdjj4@centurylink.net |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael McClure |
mdjj4@centurylink.net |
Self |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
277 |
2020-10-08 14:21 |
Anonymous (not verified) |
173.18.16.129 |
Mb Construction and Real Estate LLC |
Limited Liability Company |
5375 Katelyn Ave Van Meter, IA 50261 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-08 |
Michael Mohr |
mike@mohrhomesia.com |
Van Meter |
Dallas |
Iowa |
Lesa Reeves |
Samantha Hartley-Bullen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MB Construction and Real Estate LLC |
mike@mohrhomesia.com |
Owner |
Van Meter |
Dallas |
Iowa |
Lesa Reeves |
Samantha Hartley-Bullen |
Signed |
404 |
2021-02-16 13:30 |
Anonymous (not verified) |
174.198.79.179 |
Topline Painting llc |
Limited Liability Company |
1603 e 32nd 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. |
2021-02-16 |
Michael nunez |
toplinepaintingiowa@gmail.com |
Des Moines |
Polk |
Iowa |
Jimmy nunez |
Jose Nunez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael nunez |
toplinepaintingiowa@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Jimmy nunez |
Jose nunez |
Signed |
1646 |
2023-05-15 13:13 |
Anonymous (not verified) |
94.188.207.224 |
Aspen leaf Painting |
Limited Liability Company |
3846 Lower Beaver 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. |
2023-05-15 |
Michael Patrick Vajda |
m.p.vajda@gmail.com |
Des Moines |
Polk |
IA |
Patrick Vajda |
Mike Vajda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Vajda |
m.p.vajda@gmail.com |
Self |
Des Moines |
Polk |
IA |
Mike Vajda |
Michael Vajda |
Signed |
1641 |
2023-05-11 13:40 |
Anonymous (not verified) |
94.188.207.228 |
Mike Weigel Construction, LLC |
Limited Liability Company |
2528 Dalton St, Ames IA 50010-1151 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Michael Patrick Weigel |
mikeweigelconstruction@gmail.com |
Ames |
Story |
Iowa |
Brenda Marie Weigel |
Piper Rylee Weigel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Patrick Weigel |
mikeweigelconstruction@gmail.com |
Self |
Ames |
Story |
Iowa |
Brenda Marie Weigel |
Piper Rylee Weigel |
Signed |
846 |
2022-01-20 12:02 |
Anonymous (not verified) |
97.107.199.129 |
Moval Motors LLC |
Limited Liability Company |
3153 Joliet Ave Missouri Valley IA 51555 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-19 |
Michael Porter |
msporter8855@hotmail.com |
Papillion |
sarpy |
Nebraska |
Jon Paul Burton |
Scott Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Micahel Porter |
mporter8855@hotmail.com |
secretary of Moval |
Papillion |
Sarpy |
Nebraska |
Jon Paul Bruton |
Scott Porter |
Signed |
1993 |
2024-01-23 07:36 |
Anonymous (not verified) |
94.188.205.168 |
Leaf Home Solutions LLC |
Limited Liability Partnership |
1595 Georgetown Road 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. |
2024-01-23 |
Michael Rice |
wildblueed@gmail.com |
Middle Amana |
Iowa |
Iowa |
Sylvia Rice |
Russel Hospadarsky |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Acosta |
macosta@leafhome.com |
recruiter |
Hudson |
Summit |
Ohio |
Sylvia Rice |
Russel Hospadarsky |
Signed |
88 |
2020-03-11 15:45 |
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. |
2021-03-11 |
Michael Schiffer |
Mike502B@aol.com |
Ovid |
Clinton |
MI |
Seth Alexander |
Nicholas Crofoot |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Albert Schiffer |
Al400@aol.com |
employee |
Ovid |
Clinton |
Michigan |
Seth Alexander |
Nicholas Crofoot |
Signed |
365 |
2021-01-15 11:24 |
Anonymous (not verified) |
63.227.74.126 |
Paramount Kitchen and Bath |
Limited Liability Company |
2155 SE 37TH ST STE C |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-15 |
Michael Simpson |
mike@paramount-kitchens.com |
GRIMES |
Iowa |
United States |
Cory Morris |
Jason Andersen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Simpson |
mike@paramount-kitchens.com |
Owner |
GRIMES |
Iowa |
United States |
Cory Morris |
Jason Andersen |
Signed |
752 |
2021-11-17 08:22 |
Anonymous (not verified) |
166.181.82.81 |
Michael sprout |
Limited Liability Company |
1208 N THORNWOOD 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. |
2021-10-14 |
Michael Sprout |
1293newhome@gmail.com |
Davenport |
IA |
IA |
Mike smith |
Doug palmer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Sprout |
1293newhome@gmail.com |
Geico |
Davenport |
IA |
IA |
Mike smith |
Doug palmer |
Signed |
1426 |
2023-01-19 17:14 |
Anonymous (not verified) |
96.19.118.202 |
Tri State Certified LLC |
Limited Liability Company |
4755 Mayhew 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. |
2023-01-19 |
Michael Tracy |
mikertracy755@gmail.com |
Sioux City |
IA |
United States |
Michael Tracy |
Michael Tracy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tri State Certified LLC |
mikertracy755@gmail.com |
Owner |
Sioux City |
Iowa |
Iowa |
Michael Tracy |
Michael Tracy |
Signed |
104 |
2020-03-26 19:00 |
Anonymous (not verified) |
173.189.167.170 |
MCB CONSTRUCTION INC |
Limited Liability Company |
3484 VERMONT ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-26 |
michael wade bethards |
mwbethards@yahoo.com |
NEW VIRGINIA |
IA |
IA |
noel isaac |
alice lohmann |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
mike bethards |
mwbethards@yahoo.com |
owner |
New Virginia |
warren |
IA |
noel isaac |
alice lohmann |
Signed |
1415 |
2023-01-09 10:50 |
Anonymous (not verified) |
73.103.30.27 |
MWK Solutions, LLC |
Limited Liability Company |
1001 South Park St., 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. |
2023-01-09 |
Michael Wayne Koch |
mwkpar@gmail.com |
Fairfield |
Jefferson |
Iowa |
Ann Koch |
David Fleming |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Wayne Koch |
mwkpar@gmail.com |
Self |
Fairfield |
Jefferson |
Iowa |
Ann Koch |
David Fleming |
Signed |
793 |
2021-12-14 14:16 |
Anonymous (not verified) |
174.22.96.99 |
Dubuque County Energy District |
Limited Liability Company |
700 Locust Street, #195 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-10 |
Michaela Marie Freiburger |
michaela@energydistrict.org |
Dubuque |
Dubuque |
IA |
Diane Freiburger, Mother |
Michael Freiburger, Father |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michaela Marie Freiburger |
michaela@energydistrict.org |
Contracted Vendor for the Dubuque County Energy District |
Dubuque |
Dubuque |
IA |
Diane Freiburger |
Michael Freiburger |
Signed |
815 |
2021-12-28 12:29 |
Anonymous (not verified) |
173.29.239.122 |
Comtek, Inc. |
Proprietorship |
3702 NW 13th 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. |
2021-12-28 |
Micheal D. Qualley |
mqcomtek@gmail.com |
ANKENY |
IA |
United States |
Jacque Blackman |
Jeffery Keipper |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacque Blackman |
jblackman@grimesfinancialgroup.com |
client |
Grimes |
Polk |
Iowa |
Jacque Blackman |
Jeffery Keipper |
Signed |
1268 |
2022-08-18 15:01 |
Anonymous (not verified) |
75.162.65.221 |
Furgy's Carpet |
Limited Liability Company |
6930 NE 56th St Lot 92, 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. |
2022-08-18 |
Micheal Furgison |
furgy4f@gmail.com |
Altoona |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Micheal Furgison |
furgy4f@gmail.com |
Self |
Altoona |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
1356 |
2022-11-02 08:21 |
Anonymous (not verified) |
174.215.249.84 |
Leaf home solutions |
Proprietorship |
1595 Georgetown Road, 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. |
2022-11-02 |
Micheal Wills |
mwills5304@gmail.com |
Granger |
Polk |
IA |
Bryanna Wills |
Andrew Vannausdle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryanna Wills |
bryannawills725@gmail.com |
None |
Granger |
Polk |
IA |
Andrew Vannausdle |
Micheal Wills |
Signed |
577 |
2021-07-16 13:45 |
Anonymous (not verified) |
204.155.61.217 |
Chris & Michele Burke dba Studio Dance |
Proprietorship |
3907 Center Point 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-07-16 |
Michele Burke |
michele@studiodanceia.com |
Marion |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Michele Burke |
michele@studiodanceia.com |
owner |
Marion |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
121 |
2020-04-14 15:11 |
Anonymous (not verified) |
173.31.176.75 |
Society of St. Vincent de Paul, District council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Michele E Collison |
darmstad48@aol.com |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
Secretary of the St. Vincent de Paul District Council of Waterloo, Iowa, Inc. |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
1500 |
2023-03-07 11:22 |
Anonymous (not verified) |
94.188.205.177 |
KATEN LLC |
Limited Liability Company |
5100 S ASH GROVE AVE SIOUX FALLS, SD, 57108 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-27 |
MICHELLE KATEN |
JOEL@WALKERINSURANCEIA.COM |
SIOUX FALLS |
MINNEHAHA |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MICHELE KATEN |
JOEL@WALKERINSURANCEIA.COM |
SELF |
SIOUX FALLS |
MINNEHAHA |
SD |
JOSEPH THOMAS LORINGJ |
JENNIFER JANET YOUNGWIRTH |
Signed |
1795 |
2023-08-11 08:02 |
Anonymous (not verified) |
94.188.205.176 |
Overall Cleaning |
Proprietorship |
507 Enterprise Ct #6 Independence IA 50644 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-11 |
Michelle L. Vonsprecken |
michelle.vonsprecken@gmail.com |
Independence |
Buchanan |
Iowa |
Jacob Von Sprecken |
Cody Caraway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin C Hayes |
overallcleaning21@gmail.com |
Business Partner |
Marion |
Linn |
IA |
Cody Caraway |
Jacob Von Sprecken |
Signed |
794 |
2021-12-14 14:18 |
Anonymous (not verified) |
65.144.174.26 |
iDesign |
Limited Liability Company |
805 15th 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. |
2021-12-14 |
Michelle Wiedman |
idesigninside@gmail.com |
Dallas Center |
Dallas |
IA |
Carl Sprague |
Neal Bunn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michelle Wiedman |
idesigninside@gmail.com |
Self |
Dallas Center |
Dallas |
Iowa |
Carl Sprague |
Neal Bunn |
Signed |
1052 |
2022-04-14 19:05 |
Anonymous (not verified) |
140.82.187.220 |
McHaddy Constuction |
Proprietorship |
423 Railroad 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. |
2022-04-14 |
Mick Haddeman |
mick@mchaddyconstruction.com |
Hudson |
Iowa |
United States |
Linsey Jo Haddeman |
Jordan Renae Haddeman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Haddeman |
mick@mchaddyconstruction.com |
self |
Hudson |
IA |
United States |
Linsey Jo Haddeman |
Jordan Renae Haddeman |
Signed |
449 |
2021-03-25 10:53 |
Anonymous (not verified) |
174.198.73.94 |
A&F Painting llc |
Limited Liability Company |
411 E Dunham 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. |
2021-03-25 |
Miguel Afanador Olguin |
mafanador02@gmail.com |
Des Moines |
Polk |
Iowa |
Alfonzo Afanador |
Noemi Afanador |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Afanador Olguin |
mafanador02@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Alfonzo Alfanador |
Noemi Alfanador |
Signed |
754 |
2021-11-19 08:27 |
Anonymous (not verified) |
65.144.174.26 |
miguel albino |
Proprietorship |
8760 cody dr. unit 107 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. |
2021-11-19 |
miguel albino |
albino.miguel627@gmail.com |
west des moines |
united states |
iowa |
humbeto albino |
johnothan albino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
miguel albino |
albino.miguel627@gmail.com |
self |
west des moines |
united states |
iowa |
humberto albino |
johnothan |
Signed |
180 |
2020-06-09 13:35 |
Anonymous (not verified) |
99.203.113.208 |
Z & Sons handyman company LLC |
Limited Liability Company |
2701 E Market St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-09 |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Des Moines |
Polk |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Z & Sons handyman company LLC is owned by agent |
Des Moines |
Polj |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
181 |
2020-06-09 20:44 |
Anonymous (not verified) |
75.162.15.198 |
Z & Sons handyman company LLC |
Limited Liability Company |
2701 E Market St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-09 |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Des Moines |
Polk |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Z & Sons handyman company LLC is owned by agent |
Des Moines |
Polk |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
1602 |
2023-04-25 20:10 |
Anonymous (not verified) |
94.188.207.228 |
Miguel D. |
Limited Liability Company |
1221 22nd st des moines ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-21 |
Miguel Duron |
Duron6478@gmail.com |
Des moines |
Polk |
Ia |
Uziel martinez |
Cesar jaz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Duron |
Diron6478@gmail.com |
Self |
Des moines |
Polk |
Iowa |
Uziel Martinez |
Cesar jaz |
Signed |
42 |
2020-01-24 12:26 |
Anonymous (not verified) |
173.24.181.211 |
MIKE EDDY |
Proprietorship |
PO BOX 437 OKOBOJI, IA 51355 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-22 |
MIKE EDDY |
joel@walkerinsuranceia.com |
OKOBOJI |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MIKE EDDY |
JOEL@WALKERINSURANCEIA.COM |
OWNER |
OKOBOJI |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1498 |
2023-03-07 11:20 |
Anonymous (not verified) |
94.188.205.176 |
KATEN LLC |
Limited Liability Company |
5100 S ASH GROVE AVE SIOUX FALLS, SD 57108 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
MIKE KLEIN |
joel@walkerinsuranceia.com |
SIOUX FALLS |
MINNEHAHA |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MIKE KLEIN |
JOEL@WALKERINSURANCEIA.COM |
SELF |
SIOUX FALLS |
MINNEHAHA |
SD |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
721 |
2021-11-05 14:04 |
Anonymous (not verified) |
209.252.172.87 |
Mike Kraus |
Proprietorship |
212 2nd 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. |
(1) I am not electing the employers’ liability coverage. |
2020-03-17 |
Mike Kraus |
mjkraus4356@gmail.com |
Buffalo |
Scott |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Kraus |
mjkraus4356@gmail.com |
Self Employed |
Buffalo |
Scott |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
800 |
2021-12-15 16:50 |
Anonymous (not verified) |
63.229.189.35 |
CT Home Services |
Limited Liability Company |
706 Jackson Avenue, 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. |
2021-12-15 |
Mike Oolman |
mikecthome@gmail.com |
Spirit lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Oolman |
mikecthome@gmail.com |
Self |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
2022 |
2024-02-02 12:24 |
Anonymous (not verified) |
94.188.205.175 |
Short's Lawn Care LLC. |
Limited Liability Company |
309 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. |
2024-02-02 |
Mike Short |
Shortslawns@gmail.com |
REDFIELD |
IA |
United States |
Michael Thomas Short |
Michael Short |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Short |
Shortslawns@gmail.com |
Owner |
REDFIELD |
IA |
United States |
Michael Thomas Short |
Michael Short |
Signed |
679 |
2021-10-18 13:14 |
Anonymous (not verified) |
173.18.22.217 |
Xscape Extreme Hard & Landscape |
Proprietorship |
3215 E 25th CT Bldg 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. |
2021-10-18 |
Mike Tapper |
Tapper4981@gmail.com |
Des Moines |
Polk |
IA |
Lesa Dillon |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Tapp |
Tapper4981@gmail.com |
Owner |
Des Moines |
Des Moines |
IA |
Lesa Dillon |
Kelly Coluzzi |
Signed |
1812 |
2023-08-22 08:00 |
Anonymous (not verified) |
94.188.207.230 |
mike bethards |
Proprietorship |
3484 vermont st new virginia ia 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. |
2023-08-22 |
mike w bethards |
mwbethards@yahoo.com |
new virginia |
ia |
United States |
christine bethards |
alice lohan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
mike bethards |
mwbethards@yahoo.com |
same |
new virginia |
ia |
United States |
christine bethards |
alice lohan |
Signed |
2158 |
2024-04-17 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Mildred Lopez |
Proprietorship |
214 1st Ave SW 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. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Mark Morrison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Mark Morrison |
Signed |
2159 |
2024-04-17 12:28 |
Anonymous (not verified) |
94.188.207.229 |
Mildred Lopez Camacho |
Proprietorship |
214 1st Ave SW 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. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Jonathan Morales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Jonathan Morales |
Signed |
34 |
2020-01-10 15:56 |
Anonymous (not verified) |
74.84.121.206 |
Milferd Loewen |
Proprietorship |
6568 Hwy 63, Lime Springs, IA 52155 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-10 |
Milferd Loewen |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel J. Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Milferd Loewen |
darrele@ciains.biz |
self |
Lime Springs |
Howard |
Iowa |
Darrel J. Elsbernd |
Chris Fye |
Signed |
1453 |
2023-02-14 07:19 |
Anonymous (not verified) |
94.188.207.230 |
Milton Gray |
Proprietorship |
255 10th Ave., Marion, IA 52302, 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. |
2023-02-13 |
Milton Gray |
miltongray23@gmail.com |
Marion, IA |
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 |
MO |
Charles Wood |
Steven Geisler |
Signed |
1015 |
2022-03-29 10:56 |
Anonymous (not verified) |
129.255.1.117 |
Alli Center |
Proprietorship |
1150 5th St Suite 270 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. |
2022-03-29 |
Miranda K Maday |
miranda.maday@alli-center.com |
North Liberty |
Johnson |
Iowa |
Zara Wanlass |
Jason Knight |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zara Wanlass |
zara.wanlass@alli-center.com |
Co-Owner and Business Manager |
Iowa City |
Johnson |
IA |
Miranda K Maday |
Jason Knight |
Signed |
1181 |
2022-07-06 10:10 |
Anonymous (not verified) |
173.18.22.217 |
MB Masonry LLC |
Limited Liability Company |
PO Box 7534 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Mirela Atajic |
mbmasonryllc@yahoo.com |
Urbandale |
Polk |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mirela Atajic |
mbmasonryllc@yahoo.com |
Owner |
Urbandale |
Polk |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
2125 |
2024-03-28 23:17 |
Anonymous (not verified) |
94.188.207.223 |
MB Lawn Care |
Limited Liability Company |
7018 Deerview 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. |
2024-03-28 |
Mirnes Becirovic |
Mirnes2012@me.com |
Urbandale |
Polk |
Iowa |
Mirnes Becirovic |
Mirnes Becirovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mirnes Becirovic |
mirnes2012@me.com |
Owner |
Urbandale |
Polk |
Iowa |
Mirnes Becirovic |
Mirnes Becirovic |
Signed |
1796 |
2023-08-13 13:35 |
Anonymous (not verified) |
94.188.205.176 |
Mirsad Mulic |
Limited Liability Company |
7094 Hickory 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. |
2023-08-13 |
Mirsad Mulic |
finecarpentry30@icloud.com |
Urbandale |
Polk |
IA |
Peter Griffin |
Andy Dufre |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fine Carpentry |
finecarpentry30@icloud.com |
Partner |
Urbandale |
Polk |
IA |
Griffin Peterson |
Andy Dufre |
Signed |
227 |
2020-08-07 13:47 |
Anonymous (not verified) |
173.28.28.57 |
Coffee Grounds, LLC dba Bev & Hennie's |
Limited Liability Company |
604 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. |
2020-07-28 |
Missy Schellhorn |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Missy Schellhorn |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
695 |
2021-10-26 17:22 |
Anonymous (not verified) |
208.126.118.243 |
Godes Farms Trucking LLC |
Limited Liability Company |
1698 270th 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. |
2021-10-26 |
Mitchel R Godes |
mitchelgodes@hotmail.com |
Delmar |
clinton |
iowa |
Dustin Kyarsgaard |
Mitch Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchel R Godes |
mitchelgodes@hotmail.com |
owner |
Delmar |
Clinton |
iowa |
Dustin KKyarsgaard |
Mitch Moore |
Signed |
1092 |
2022-05-09 17:49 |
Anonymous (not verified) |
199.247.76.21 |
Mitchell Ellison |
Limited Liability Company |
906 Lakeshore 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. |
2022-05-09 |
Mitchell Ellison |
Essential.ellison@gmail.com |
Lakeside |
Iowa |
United States |
Mitchell Ellison |
Mitchell Ellison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Ellison |
Essential.ellison@gmail.com |
Self |
Lakeside |
Iowa |
United States |
Mitchell Ellison |
Mitchell Ellison |
Signed |
1760 |
2023-07-26 08:16 |
Anonymous (not verified) |
94.188.207.230 |
MCH Pig LLC |
Limited Liability Company |
5434 180th Ave Albert City, IA 50510 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Mitchell Hogrefe |
mhogrefe@nfpinc.com |
Newell |
Buena Vista |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Hogrefe |
mhogrefe@nfpinc.com |
Owner |
Newell |
Buena Vista |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
713 |
2021-11-05 10:41 |
Anonymous (not verified) |
64.5.73.247 |
Mitchell 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 |
Mitchell Langel |
gklangel@netins.net |
Templeton |
Carroll |
Iowa |
Jonathan Heydon |
Lacey Marsh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Langel |
gklangel@netins.net |
Owner |
Templeton |
Carroll |
Iowa |
Jonathan Heydon |
Lacey Marsh |
Signed |
1417 |
2023-01-11 08:55 |
Anonymous (not verified) |
174.235.209.245 |
Standard Insulation Company, LLC |
Limited Liability Company |
1066 Prairieview Ave., Van Meter, IA 50261 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-11 |
Mitchell Simonson |
standard.insulation@outlook.com |
Van Meter |
Madison |
IA |
Jeremy Smith |
Sue Sherman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Simonson |
standard.insulation@outlook.com |
Owner |
Van Meter |
Madison |
IA |
Jeremy Smith |
Sue Sherman |
Signed |
744 |
2021-11-11 15:22 |
Anonymous (not verified) |
72.13.16.172 |
MJL TRANSPORT |
Proprietorship |
PO BOX 3301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
MJL TRANSPORT |
dave@allseasonstrucking.com |
DUBUQUE |
DUBUQUE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MJL TRANSPORT |
dave@allseasonstrucking.com |
PRESIDENT |
DUBUQUE |
DUBUQUE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
660 |
2021-09-30 14:15 |
Anonymous (not verified) |
172.58.86.219 |
LeafFilter |
Limited Liability Company |
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. |
2021-09-30 |
Mohammed Albayati |
mmm2002faris@yahoo.com |
West Des Moines |
Polk |
Iowa |
Tammy Decker |
Yaseen Albayati |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mohammed Albayati |
albayatim28@gmail.com |
Employee |
Grimes |
Polk |
Iowa |
Tammy Decker |
Yaseen Albayati |
Signed |
1233 |
2022-07-28 22:53 |
Anonymous (not verified) |
166.181.84.53 |
Leaffilter |
Limited Liability Company |
3060 SE Grimes Blvd Suite 100-300, Grimes, IA 501113060 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. |
2022-07-28 |
Mohammed Albayati |
mrcarbody.81@gmail.com |
Johnston |
Polk |
Iowa |
Tammy Decker |
Waffa Albayati |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meghan Mcilhon |
mmcilhon@leaffilter.com |
Human Resources |
Grimes |
Polk |
Iowa |
Tammy Decker |
Waffa Albayati |
Signed |
970 |
2022-03-14 14:08 |
Anonymous (not verified) |
174.199.79.176 |
Friends Transportation Services LLC |
Limited Liability Company |
6010 Creston Ave Unit 26, 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. |
2022-03-14 |
Mohammed Dood |
mohedali777@hotmail.com |
Des Moines |
Polk |
Iowa |
Leigh Laven |
Geoff Matlock |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mohammed Dood |
mohedali777@hotmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Leigh Laven |
Geoff Matlock |
Signed |
1632 |
2023-05-09 11:10 |
Anonymous (not verified) |
94.188.205.177 |
MM Drywall LLC Moises Melo Santiago |
Proprietorship |
7500 Bloomfield Road Lot 78 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-01 |
Moises Melo Santiago |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
kelly Denger |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MM Drywall LLC Moises Melo Santiago |
deb@piciowa.com |
self |
Des Moines |
polk |
Iowa |
Kelly Denger |
Debra Stratton |
Signed |
886 |
2022-02-03 10:21 |
Anonymous (not verified) |
217.180.228.144 |
Flo + Friends, LLC |
Limited Liability Company |
52480 HWY 210 Slater, IA. 50244 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Molly S Onken |
mollyaols@gmail.com |
Slater |
Story |
Iowa |
Pam Wilson |
Todd Wilson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Molly S Onken |
mollyaols@gmail.com |
self |
slater |
Story |
Iowa |
Pam Wilson |
Todd Wilson |
Signed |
1481 |
2023-02-24 12:45 |
Anonymous (not verified) |
94.188.207.223 |
Molly Onken |
Limited Liability Company |
52480 HWY 210 Slater, IA. 50244 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Molly S Onken |
mollyaols@gmail.com |
Slater |
Story |
Iowa |
Pamela A Wilson |
Lori Konzen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Molly S Onken |
mollyaols@gmail.com |
Owner |
Slater |
Story |
Iowa |
Pamela A Wilson |
Lori Konzen |
Signed |
71 |
2020-02-21 05:24 |
Anonymous (not verified) |
70.100.107.197 |
CRS Inc. |
Proprietorship |
1442 3rd 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. |
2020-01-20 |
Monica Christensen |
monicalchristensen@gmail.com |
Belmond |
Wright |
Iowa |
Jessica Tempus |
Dawn Butler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Christensen |
monicalchristensen@gmail.com |
Consultant |
Belmond |
Iowa |
United States |
Dawn Butler |
Jessica Tempus |
Signed |
58 |
2020-02-10 21:18 |
Anonymous (not verified) |
75.162.11.63 |
Moni tile Services llc |
Limited Liability Company |
2207 E Walnut St des Moines iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-01 |
Monica M Sandoval |
Mjsandoval20@yahoo.com |
Des Moines |
Polk |
United States |
Cassie Ann bentz |
James wesley harkert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Moni tile services llc |
Mjsandoval20@yahoo.com |
Self |
Des Moines |
Polk |
Iowa |
Cassie Ann bentz |
James wesley harkert |
Signed |
1348 |
2022-10-28 10:19 |
Anonymous (not verified) |
208.38.230.122 |
HALSEY'S HOME IMPROVEMENTS, LLC |
Limited Liability Company |
126 SYCAMORE LANE, RIVERDALE, 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. |
2022-10-28 |
MONTY RAY HALSEY |
crickstic@gmail.com |
RIVERDALE |
SCOTT |
IA |
DARRELL MACHALEK JR. |
MATTHEW DAVISON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MONTY HALSEY |
crickstic@gmail.com |
SELF |
RIVERDALE |
SCOTT |
IA |
DARRELL MACHALEK JR. |
MATTHEW DAVISON |
Signed |
1147 |
2022-06-08 11:29 |
Anonymous (not verified) |
67.55.184.250 |
Morgan Anderson |
Proprietorship |
23379 120th Ave, Mediapolis, IA 52637 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Morgan Duane Anderson |
morgananderson6.ma@gmail.com |
Mediapolis |
IA |
United States |
Kelly S Lanz |
Monte A Lanz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Morgan D. Anderson |
morgananderson6.ma@gmail.com |
sole proprietor |
Mediapolis |
Louisa |
Iowa |
Kelly Lanz |
Monte Lanz |
Signed |
1030 |
2022-04-05 06:27 |
Anonymous (not verified) |
172.58.86.173 |
MR Roofing LLC |
Limited Liability Company |
8012 Ashridge Rd. Fort Worth, Tx 76134 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
MR Roofing LLC |
mrroofing.pr@gmail.com |
Fort Worth |
Tarrant |
Texas |
Juan M. Robledo |
Jose A. Robledo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Robledo |
mrroofing.pr@gmail.com |
Owner |
Fort Worth |
Tarrant |
Texas |
Juan M. Robledo |
Jose A. Robledo |
Signed |
1046 |
2022-04-14 08:11 |
Anonymous (not verified) |
104.36.120.68 |
jet drywall |
Limited Liability Company |
5611 westminster DR #5 cedarfalls 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. |
2022-04-14 |
murion jones |
jetdrywall.construction@gmail.com |
cedarfalls |
black hawk |
iowa |
murion parely jones |
murion jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
murion jones |
jetdrywal.construction@gmail.com |
owner |
cedarfalls |
black hawk |
iowa |
Murion Jones JR |
Eric Jones |
Signed |
1047 |
2022-04-14 08:11 |
Anonymous (not verified) |
104.36.120.68 |
jet drywall |
Limited Liability Company |
5611 westminster DR #5 cedarfalls 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. |
2022-04-14 |
murion jones |
jetdrywall.construction@gmail.com |
cedarfalls |
black hawk |
iowa |
murion parely jones |
murion jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
murion jones |
jetdrywal.construction@gmail.com |
owner |
cedarfalls |
black hawk |
iowa |
Murion Jones JR |
Eric Jones |
Signed |
1800 |
2023-08-14 20:24 |
Anonymous (not verified) |
94.188.207.227 |
Laven Snow Removal LLC |
Limited Liability Company |
413 SE 6th street 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. |
2023-08-14 |
Myles John Laven |
lavensnowremoval@gmail.com |
Ankeny |
Polk |
Iowa |
Megan Rose Nefzger |
Mackale Joel Laven |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Myles John Laven |
lavensnowremoval@gmail.com |
Owner |
Ankeny |
Polk |
Iowa |
Megan Rose Nefzger |
Mackale Joel laven |
Signed |
1087 |
2022-05-04 12:32 |
Anonymous (not verified) |
67.212.117.157 |
Polk's Lock Service, Inc. |
Limited Liability Partnership |
1504 College 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. |
2022-05-04 |
Myron Piehl |
polkslockservice@gmail.com |
Cedar Falls |
IA |
United States |
Jonathon Illian |
Katrina Reyerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Myron John Piehl |
polkslockservice@gmail.com |
owner |
Cedar Falls |
IA |
United States |
Jonathan Illian |
Katrina Clair Reyerson |
Signed |
439 |
2021-03-18 08:09 |
Anonymous (not verified) |
172.58.86.251 |
Nancy Lopez/Lifetime Roofing and Construction Corpn |
Proprietorship |
2234 Highland St 50315 Des Moines IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-18 |
Nancy Lopez/ Lifetime Roofing and Construction Corp |
info@lifetimeroofingdsm.com |
Des Moines |
Polk |
I A |
Noe Ordaz |
Fidel Rubio |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nancy Lopez |
info@lifetimeroofingdsm.com |
Owner |
Des Moines |
Polk |
IA |
Noe Ordaz |
Fidel Rubio |
Signed |
1119 |
2022-05-18 11:51 |
Anonymous (not verified) |
104.201.75.222 |
Gentry Hardware inc. |
Partnership |
308 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. |
2022-05-18 |
Nathan Dwaine Gentry |
gentrynathan@hotmail.com |
Rockwellcity |
Calhoun |
Iowa |
Emily Bethann Gentry |
Amanda Margaret Albee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Dwaine Gentry |
gentrynathan@hotmail.com |
Owner |
Rockwellcity |
Calhoun |
Iowa |
Emily Bethann Gentry |
Amanda Margaret Albee |
Signed |
1005 |
2022-03-24 14:34 |
Anonymous (not verified) |
165.225.57.246 |
Beardmore Construction |
Limited Liability Company |
404 E 1st 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. |
2022-01-01 |
Nathan Fosenburg |
nfosenburg@yahoo.com |
Indianola |
Warren |
IA |
Kerri Fosenburg |
Nathan Fosenburg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Fosenburg |
nfosenburg@yahoo.com |
owner |
Indianola |
Warren |
IA |
Kerri Fosenburg |
Nathan Fosenburg |
Signed |
1489 |
2023-02-28 16:06 |
Anonymous (not verified) |
94.188.207.228 |
Nate's Tractor LLC |
Limited Liability Company |
11939 birch Ave Riceville, IA 50466 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-28 |
Nathan Fox |
nate@natestractor.com |
Riceville |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Fox |
nate@natestractor.com |
Member |
Riceville |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
506 |
2021-05-10 09:29 |
Anonymous (not verified) |
199.102.211.129 |
Nathan J Hurst LLC DBA J&K Construction |
Limited Liability Company |
3598 Orchard Rd. Osage, IA 50461 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Nathan J Hurst |
jkconstructionjake@yahoo.com |
Osage |
Mitchell |
Iowa |
Breanna Fox |
Karl Herman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Breanna Fox |
jkconstructionjake@yahoo.com |
Office Manager |
Osage |
Mithell |
Iowa |
Nathan J Hurst |
Karl F Herman |
Signed |
753 |
2021-11-17 22:09 |
Anonymous (not verified) |
107.77.219.76 |
Shaw Livestock, LLC. |
Limited Liability Company |
6871 275th Street, Moravia, IA 52571-8003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-11-17 |
Nathan Nash Shaw |
nathan@shawlivestock.com |
Moravia |
Monroe |
Iowa |
Scott Saveraid |
Sandra Blindauer |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Nathan Shaw |
nathan@shawlivestock.com |
Self |
Moravia |
Monroe |
Iowa |
Scott Saveraid |
Sandra Blindauer |
Signed |
319 |
2020-11-16 19:24 |
Anonymous (not verified) |
173.30.37.132 |
Nathan Wright |
Proprietorship |
500 2nd Avenue, Charles City, Iowa 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. |
2020-11-16 |
Nathan Robert Wright |
nrwright85@yahoo.com |
Charles City |
Floyd |
Iowa |
Jeff Wright |
Marsha Wright |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Robert Wright |
nrwright85@yahoo.com |
Self |
Charles City |
IA |
IA |
Jeff Wright |
Marsha Wright |
Signed |
550 |
2021-06-25 16:20 |
Anonymous (not verified) |
165.225.61.18 |
Shaw Livestock, LLC |
Limited Liability Company |
6871 275th Street, Moravia, IA 52571-8003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-06-25 |
Nathan Shaw |
nate@shawlivestock.com |
Moravia |
Appanoose |
Iowa |
Scott Saveraid |
Alexa Sheeder |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Nathan Shaw |
nate@shawlivestock.com |
Self |
Moravia |
Appanoose |
Iowa |
Scott Saveraid |
Alexa Sheeder |
Signed |
1979 |
2024-01-08 14:59 |
Anonymous (not verified) |
94.188.205.167 |
Nathan Troendle |
Proprietorship |
Lansing 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. |
2024-01-05 |
Nathan Troendle |
darrele@ciains.biz |
Lansing |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Troendle |
darrele@ciains.biz |
self |
Lansing |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
248 |
2020-08-27 16:01 |
Anonymous (not verified) |
142.202.101.194 |
Nathan Unruh Construction |
Proprietorship |
P.O. Box 181 Mechanicsville, IA. 52306 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-27 |
Nathan Unruh |
Nathanunruh@gmail.com |
Mechanicsville |
Cedar |
Iowa |
Randy Rouse |
Bruce Seehusen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Unruh |
nathanunruh@gmail.com |
Same person |
Mechanicsville |
Cedar |
Iowa |
Randy Rouse |
Bruce Seehusen |
Signed |
1924 |
2023-11-27 12:17 |
Anonymous (not verified) |
94.188.205.166 |
Leaf Home 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. |
2023-11-27 |
Nathaniel Brundidge |
nateotto1313@gmail.com |
Osceola |
Warren |
IA |
Barb Dryer |
Bob Dryer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Acosta |
macosta@leafhome.com |
Employee |
Hudson |
Summit |
Ohio |
Barb Dryer |
Bob Dryer |
Signed |
1100 |
2022-05-13 12:54 |
Anonymous (not verified) |
50.83.96.157 |
Spindrift LLC |
Limited Liability Company |
2825 Newport Rd 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. |
2022-05-13 |
Nathaniel James Dooley |
spindriftlawnandsnow@gmail.com |
Iowa City |
Johnson |
Iowa |
Sharon Dooley |
Kristen Simpson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathaniel James Dooley |
spindriftlawnandsnow@gmail.com |
Same |
Iowa City |
Johnson |
Iowa |
Sharon Dooley |
Kristen Simpson |
Signed |
1206 |
2022-07-14 14:34 |
Anonymous (not verified) |
75.162.163.45 |
General construction services |
Proprietorship |
7071 30th 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. |
2022-07-14 |
ned cunconan |
ned.gcs@gmail.com |
Norwalk |
polk |
IA |
Sheena Cunconan |
Sheena Cunconan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ned cunconan |
ned.gcs@gmail.com |
subcontractor |
Norwalk |
polk |
Iowa |
Sheena Cunconan |
Sheena Cunconan |
Signed |
673 |
2021-10-14 07:15 |
Anonymous (not verified) |
97.125.239.203 |
Complete tile llc |
Limited Liability Company |
875 se gateway drive #311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-14 |
Nedzad mustafic |
completetile1@gmail.com |
Grimes |
Usa |
Iowa |
Enesa Mustafic |
Edina avdic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nedzad Mustafic |
completetile1@gmail.com |
Owner |
Grimes |
Usa |
Iowa |
Enesa mustafic |
Edina avdic |
Signed |
355 |
2021-01-11 16:29 |
Anonymous (not verified) |
173.18.16.129 |
Neil Bitting Construction |
Proprietorship |
2607 E 39th 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. |
2021-01-11 |
Neil Bitting |
bittingneil@live.com |
des Moines |
polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Bitting |
bittingneil@live.com |
owner |
des moines |
polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
2202 |
2024-05-06 11:36 |
Anonymous (not verified) |
94.188.207.224 |
Neil Wedeking |
Proprietorship |
408 Maple St, Nemaha, IA 50567 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-06 |
Neil Douglas Wedeking |
nandjwedeking@frontiernet.net |
Nemaha |
Sac |
Iowa |
Joseph McCollum |
Heather Husman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Wedeking |
nandjwedeking@frontiernet.net |
Self |
Nemaha |
Sac |
Iowa |
Joseph Paul McCollum |
Heather Lee Husman |
Signed |
2032 |
2024-02-07 11:05 |
Anonymous (not verified) |
94.188.207.229 |
NEIL MARTENS |
Proprietorship |
527 3RD STREET, SOUTH, ALBERT CITY, IA 50510 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
NEIL THIESSEN MARTENS |
pkmmartens@hotmail.com |
ALBERT CITY |
BUENA VISTA |
IOWA |
JOHN CLARENCE OLERICH |
ROBERT EUGENE BELT |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NEIL MARTENS |
pkmmartens@hotmail.com |
SELF |
ALBERT CITY |
BUENA VISTA |
IOWA |
JOHN CLARENCE OLERICH |
ROBERT EUGENE BELT |
Signed |
2055 |
2024-02-23 14:54 |
Anonymous (not verified) |
94.188.207.224 |
Neil Vonnahme |
Proprietorship |
13628 220th St., Arcadia, Iowa, 51430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-20 |
Neil Vonnahme |
neilvonnahme@gmail.com |
Arcadia |
Carroll |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Vonnahme |
neilvonnahme@gmail.com |
Self |
Arcadia |
Carroll |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
2059 |
2024-02-27 11:44 |
Anonymous (not verified) |
94.188.205.169 |
Dowdey Construction LLC |
Limited Liability Company |
1010 19th Ave - Rock Valley, IA 51247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-27 |
Nicholas Allen Dowdey |
nddowdey@hotmail.com |
Rock Valley |
Sioux |
Iowa |
Deidre Dawn Dowdey |
Alexander C Koedam |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Allen Dowdey |
nddowdey@hotmail.com |
Self |
Rock Valley |
Sioux |
Iowa |
Deidre Dawn Dowdey |
Alexander C Koedam |
Signed |
218 |
2020-07-27 19:24 |
Anonymous (not verified) |
174.217.10.15 |
Bella Exteriors LLC |
Limited Liability Company |
2908 Elm 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. |
2020-07-27 |
Nicholas Andersen |
nick@rightroofing.com |
West Des Moines |
Polk |
IA |
Tasha Palacioz |
John Kha |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Andersen |
nickande3564@gmail.com |
Self |
West Des Moines |
Polk |
IA |
Tasha Palacioz |
John Kha |
Signed |
748 |
2021-11-15 13:01 |
Anonymous (not verified) |
174.243.83.168 |
NC contracting |
Limited Liability Company |
2212 Oakwood 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. |
2021-11-15 |
Nicholas Cheney |
444nicholas@gmail.com |
Ames |
Iowa |
Iowa |
Cassie Cheney |
Shawn Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Cheney |
444nicholas@gmail.com |
Self |
Ames |
Story |
Iowa |
Cassie Cheney |
Shawn Hay |
Signed |
1790 |
2023-08-08 14:32 |
Anonymous (not verified) |
94.188.205.166 |
NJ CONSTRUCTION LLC |
Limited Liability Company |
4291 30TH AVE PETERSON, IA 51047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
NICHOLAS JAMES JONES |
njconstruction2014@hotmail.com |
PETERSON |
BUENA VISTA |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NICHOLAS JAMES JONES |
njconstruction2014@hotmail.com |
SELF |
PETERSON |
BUENA VISTA |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
2167 |
2024-04-21 22:01 |
Anonymous (not verified) |
94.188.205.177 |
The Duerson Corportaion |
Proprietorship |
601 1st Ave N, 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. |
2024-04-21 |
Nicholas John Myers |
myersnicholasj@gmail.com |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas John Myers |
myersnicholasj@gmail.com |
Owner |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
1401 |
2022-12-23 09:07 |
Anonymous (not verified) |
75.162.43.221 |
Capital Express |
Limited Liability Company |
Council is Chris Blunk out of omaha NB. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-09-09 |
Nicholas Michelfelder |
nicmichelfelder@gmail.com |
8018 Valdez Circle |
polk |
iowa |
Ted Michelfelder |
lucy Sanderson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Chris Blunk |
cblunk@harrislawomaha.com |
None |
1400 SE gateway Dr. 105 |
Polk |
IA |
Theodore Michelfelder |
Rick Isacson |
Signed |
2000 |
2024-01-26 10:05 |
Anonymous (not verified) |
94.188.205.177 |
Nick Myers Construction |
Proprietorship |
4736 Candlewick Drive, 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. |
2024-01-26 |
Nicholas Myers |
myersnicholasj@gmail.com |
Norwalk |
Warren |
Iowa |
John Myers |
Brenda Myers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Myers |
nickmyersconstruction@gmail.com |
Owner |
Norwalk |
IA |
IA |
John Myers |
Brenda Myers |
Signed |
165 |
2020-05-26 14:12 |
Anonymous (not verified) |
216.51.228.161 |
Arbor Way All About Trees |
Limited Liability Company |
417 Howard St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-26 |
Nicholas Plumski |
arborway14@gmail.com |
Saint Anthony |
Marshall |
Iowa |
Michael Richards |
Nicole Plumski |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Plumski |
arborway14@gmail.com |
Owner |
St. Anthony |
Marshall |
IA |
Michael Richards |
Nicole Plumski |
Signed |
1999 |
2024-01-25 16:57 |
Anonymous (not verified) |
94.188.205.177 |
Nicholas Schaff |
Limited Liability Company |
6934 rolling ridge ct sw cedar rapids Iowa 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. |
2024-01-25 |
Nicholas Schaff |
schaff.lawncare@gmail.com |
cedar rapids |
linn |
iowa |
Brian Zeller |
Cassie Schaff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas schaff |
schaff.lawncare@gmail.com |
Same person |
cedar rapids |
iowa |
iowa |
Brian zeller |
cassie schaff |
Signed |
1957 |
2023-12-14 18:34 |
Anonymous (not verified) |
94.188.205.166 |
Renewal by Andersen |
Limited Liability Company |
5909 OMAHA AVE N STILLWATER, MN, 55082 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Nicholas T Campbell |
hgchomes@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Kaut |
michael@rbadesmoines.com |
Employee |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
1962 |
2023-12-17 18:48 |
Anonymous (not verified) |
94.188.207.223 |
HGC Homes LLC |
Limited Liability Company |
6795 NE Rising Sun Dr 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. |
2023-12-17 |
Nicholas T Campbell |
hgchomes@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Kaut |
michael@rbadesmoines.com |
None |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
1059 |
2022-04-19 15:06 |
Anonymous (not verified) |
64.186.23.83 |
CORRECTIONVILL GOLF CLUB, INC |
Limited Liability Company |
1300 HACKBERRY STREET, CORRECTIONVILLE IOWA 51016 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
NICK HEATH |
dogboy3485@yahoo.com |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE EDWARDS |
kedwards@fnbcorrectionville.com |
SEC/TREASURER |
CORRECTIONVILLE |
WOODBURY |
IOWA |
CANDACE JACOBSON |
AMBER HANSEN |
Signed |
523 |
2021-05-17 21:46 |
Anonymous (not verified) |
173.29.90.123 |
Nick keppy |
Proprietorship |
2103 e Lombard st. Davenport iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-17 |
Nick keppy |
keppylawncare@gmail.com |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca Hein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick keppy |
keppylawncare@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Logan keppy |
Rebecca hein |
Signed |
783 |
2021-12-08 10:25 |
Anonymous (not verified) |
173.31.148.43 |
Nick Larsen |
Proprietorship |
1305 7th 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. |
2021-12-08 |
Nick Larsen |
larsennick77@gmail.com |
Milford |
Dickinson |
IA |
JOSEPH THOMAS LORING |
Kristine Ann Walker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Larsen |
joel@walkerinsuranceia.com |
Self |
Milford |
Dickinson |
IA |
JOSEPH THOMAS LORING |
Kristine Ann Walker |
Signed |
717 |
2021-11-05 13:32 |
Anonymous (not verified) |
209.252.172.87 |
Nick Wiles CW Flooring LLC |
Limited Liability Company |
Po Box 445, 710 6th St Wellman, IA 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. |
2020-06-24 |
Nick Wiles CW Flooring LLC |
nickwiles007@gmail.com |
Wellman |
Washington |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Wiles CW Flooring LLC |
nickwiles007@gmail.com |
Self Employed |
Wellman |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1157 |
2022-06-16 07:56 |
Anonymous (not verified) |
97.125.185.191 |
Apex Remodeling |
Proprietorship |
709 w. North 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. |
2022-06-15 |
Nick Winters |
nick.winters@apex-roofing.com |
WINTERSET |
Iowa |
Iowa |
Erin Winters |
Rob Tennat |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nick Winters |
nick.winters@apex-roofing.com |
Owner |
WINTERSET |
Iowa |
Iowa |
Erin Winters |
Rob Tennat |
Signed |
1301 |
2022-09-08 08:02 |
Anonymous (not verified) |
173.23.251.188 |
Nickolas Andersen |
Proprietorship |
302 E Guthrie 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. |
2022-09-08 |
Nickolas Duane Andersen |
nickandersen8888@gmail.com |
Linden |
Dallas |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nickolas Andersen |
nickandersen8888@gmail.com |
self |
Linden |
Dallas |
Iowa |
Tara Murphy |
Mike Ryerson |
Signed |
1574 |
2023-04-14 13:57 |
Anonymous (not verified) |
94.188.205.166 |
Nickolas Giebelstein |
Proprietorship |
1942 DIXWELL ST DAVENPORT IOWA 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. |
2023-04-14 |
Nickolas Giebelstein |
nickolasgiebelstein@gmail.com |
Davenport |
Scott |
Iowa |
Jeremy Francois |
Shane Nicholson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nickolas Giebelstein |
nickolasgiebelstein@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Jeremy Francois |
Shane Nicholson |
Signed |
28 |
2020-01-06 13:39 |
Anonymous (not verified) |
108.178.203.226 |
MULLIS CATTLE LLC |
Limited Liability Company |
2506 155TH ST, EARLVILLE IA 52041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
GREELEY |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
OWNER |
GREELEY |
DELAWARE |
IA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
1554 |
2023-04-04 16:30 |
Anonymous (not verified) |
94.188.205.176 |
House of Bean Studios |
Limited Liability Company |
2066 170th Street, Guthrie Center, IA 50115 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-04 |
Nicole Jazzmin Bean |
nicolebean.studios@gmail.com |
Guthrie Center |
Guthrie |
Iowa |
Daniel Bean |
Anthony Durst |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Jazzmin Bean |
houseofbeanstudios@gmail.com |
Self (Sole-proprietor LLC) |
Guthrie Center |
Guthrie |
Iowa |
Daniel Bean |
Anthony Durst |
Signed |
1291 |
2022-09-02 13:24 |
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 |
Nicole Keck |
niccikeckllc@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 |
1551 |
2023-03-31 13:37 |
Anonymous (not verified) |
94.188.205.176 |
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 |
Nicole Nadarevic |
niki@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 |
1279 |
2022-08-22 13:17 |
Anonymous (not verified) |
50.83.54.168 |
Essex Family Construction |
Limited Liability Company |
290 Monmouth St 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. |
2022-08-22 |
Niki Essex |
essexfamilycontruction@outlook.com |
Cedar Rapids |
IA |
IA |
Josh Lasond |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niki Essex |
essexfamilycontruction@outlook.com |
same |
Cedar Rapids |
Iowa |
Iowa |
Josh Lasond |
Jordan Nisiewicz |
Signed |
410 |
2021-02-19 09:23 |
Anonymous (not verified) |
166.181.84.153 |
Nikolai Charikov |
Proprietorship |
115 6th St 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. |
2021-02-19 |
Nikolai Andre Charikov |
nikolaicharikov@gmail.com |
Mitchellville |
Polk |
Iowa |
Tyler Charikov |
Mile Hufford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nikolai Charikov |
nikolaicharikov@gmail.com |
Self |
Mitchellville |
Polk |
Iowa |
Tyler Charikov |
Mile Hufford |
Signed |
1992 |
2024-01-18 21:51 |
Anonymous (not verified) |
94.188.205.175 |
NB Tile |
Proprietorship |
13310 NE 112th 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. |
2024-01-18 |
Niles Michael James Bailey |
NBtiledesign@gmail.com |
Maxwell |
IA |
United States |
Kevin Orr |
Sydney Paustian |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niles Michael James Bailey |
NBtiledesign@gmail.com |
Owner |
Mawell |
Polk |
Iowa |
Kevin Orr |
Sydney Paustian |
Signed |
1857 |
2023-10-02 16:33 |
Anonymous (not verified) |
94.188.205.169 |
Noah Blount |
Proprietorship |
2611 capitol ave, Des Moines, IA 50317, 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. |
2023-10-02 |
Noah Blount |
nbeav5@gmail.com |
Des Moines |
Des Moines |
Iowa |
Jordan Loyd |
Charles Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Jackson |
Missouri |
Jordan Loyd |
Charles Woods |
Signed |
1122 |
2022-05-21 12:19 |
Anonymous (not verified) |
173.24.108.210 |
Daly Building Service,LLc |
Limited Liability Company |
409 Dammann dr. 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. |
2022-05-21 |
Noah Daly |
Noahdalyubs@gmail.com |
Eldridge |
Scott County |
Iowa |
Holly Roberts |
Corinna Daly |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derick Perry |
biglakellc@outlook.com |
Liability policy agent |
Eldridge |
Scott county |
Iowa |
Holly roberts |
Corinna Daly |
Signed |
2052 |
2024-02-22 07:37 |
Anonymous (not verified) |
94.188.207.229 |
Noahs Ark Flooring |
Proprietorship |
6212 se 2nd 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. |
2024-02-22 |
Noah James Daggett |
daggettnoah365@gmail.com |
Des moines |
Polk |
United States |
Malichi Cerrato |
Austin tolson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Noah James Daggett |
daggettnoah365@gmail.com |
Self |
Des moines |
IA |
United States |
Malichi Cerrato |
Austin tolson |
Signed |
1123 |
2022-05-22 14:32 |
Anonymous (not verified) |
173.24.108.210 |
Daly Building Service, LLC |
Limited Liability Company |
409 Dammann Dr. 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. |
2022-05-22 |
Noah Taylor Daly |
Noahdalyubs@Gmail.com |
Eldridge |
Scott County |
Iowa |
Corinna Daly |
Holly Roberts |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Noah Taylor Daly |
Noahdalyubs@Gmail.com |
Owner |
Eldridge |
Scott County |
Iowa |
Corinna Daly |
Holly Roberts |
Signed |
1196 |
2022-07-11 08:13 |
Anonymous (not verified) |
166.181.85.207 |
KG Land works |
Proprietorship |
P.O. Box 931 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-12 |
Noah Wassom |
nowhwassom@yahoo.com |
Barnsdall |
Osage |
OKLAHOMA |
Dalton Gardner |
Jacob Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colten Kelley |
KGlandworks@gmail.com |
Boss |
Barnsdall |
Osage |
OKLAHOMA |
Keiven Slone |
Whyatt Slone |
Signed |
705 |
2021-11-02 11:41 |
Anonymous (not verified) |
173.23.180.159 |
Simri Enterprise LLC |
Limited Liability Company |
614 Ricker 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. |
2021-11-02 |
Noemi Del Carmen Trinidad |
simdelenterprisellc@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Simri Y Aldana |
simdelenterprisellc@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares |
Signed |
707 |
2021-11-03 15:30 |
Anonymous (not verified) |
173.23.180.159 |
Simdel Enterprise LLC |
Limited Liability Company |
614 Ricker 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. |
2021-11-03 |
Noemi Del Carmen Trinidad |
simdelenterprisellc@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares Axume |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Simri Y Aldana |
simdelenterprisellc@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares Axume |
Signed |
222 |
2020-08-03 16:16 |
Anonymous (not verified) |
204.98.109.114 |
Norval Craig Michael |
Proprietorship |
640 NE 47th Place, 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. |
2020-02-20 |
Norval Craig Michael |
accounts@dickersonmechanical.com |
Des Moines |
Polk |
Iowa |
Lisa Linnette Booher |
Kathryn Lou Dickerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nornal Craig Michael |
accounts@dickersonmechanical.com |
Self Employeed - Sole Proprietor |
Des Moines |
Polk |
Iowa |
Lisa Linnette Booher |
Kathryn Lou Dickerson |
Signed |
693 |
2021-10-26 15:03 |
Anonymous (not verified) |
65.144.174.26 |
Diamante Tile |
Proprietorship |
1403 Aspen 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. |
2021-10-26 |
Octavio Bermudez |
aerosobo@gmail.com |
Des Moines |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Octavio Bermudez |
aerosobo@gmail.com |
Owner |
Adel |
Dallas |
Iowa |
Antonia Bermudez |
Sofia Piatt |
Signed |
515 |
2021-05-11 15:18 |
Anonymous (not verified) |
66.188.136.150 |
Odie Mitchell |
Proprietorship |
10441 Serenity Dr. DeMotte, IN 46310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-05 |
Odie Mitchell |
kschumacher@tricorinsurance.com |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Odie Mitchell |
kschumacher@tricorinsurance.com |
Same |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
516 |
2021-05-12 12:41 |
Anonymous (not verified) |
66.188.136.150 |
Odie Mitchell |
Proprietorship |
10441 Serenity Dr. DeMotte, IN 46310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-05 |
Odie Mitchell |
kschumacher@tricorinsurance.com |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Odie Mitchell |
kschumacher@tricorinsurance.com |
Same |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
1388 |
2022-12-10 22:42 |
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 |
Oluchukwu Nwokoye |
oly@springfieldstaffing.com |
Manor |
Travis |
United States |
Beluchukwu R Ebede |
Oluchukwu Nwokoye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beluchukwu Ebede |
admin@springfield-staffing.com |
Partner |
Manor |
Travis |
United States |
Beluchukwu R Ebede |
Oluchukwu Nwokoye |
Signed |
2069 |
2024-03-01 09:55 |
Anonymous (not verified) |
94.188.207.226 |
A-1 Stone LLC |
Limited Liability Company |
4308 Boyd 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. |
2024-03-01 |
Orlando Manuel Nunez Mejia |
orlando20025@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perla Patricia Nunez |
nunezstone@gmail.com |
Employee |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2068 |
2024-03-01 09:53 |
Anonymous (not verified) |
94.188.207.226 |
A-1 Stone LLC |
Limited Liability Company |
4308 Boyd 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. |
2024-03-01 |
Orlando Nunez |
nunezstone@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perla Patricia Nunez |
nunezstone@gmail.com |
Employee |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
1287 |
2022-08-30 13:11 |
Anonymous (not verified) |
173.18.22.217 |
Gomez Painting |
Limited Liability Company |
3609 56th 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. |
2022-08-30 |
Orlyn Gomez |
orlyngomez9@gmail.com |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Orlyn Gomez |
orlyngomez9@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
73 |
2020-02-21 13:44 |
Anonymous (not verified) |
192.30.185.233 |
Viejos Masnry construction LLC |
Limited Liability Company |
1708 Villa Ave. Sioux City IA 51103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-13 |
Oscar Castro Ramirez |
veijosconstruction@gmail.com |
Sioux City |
Woodbury |
Iowa |
JEFFREY H MCCLINTOCK |
Nancy Fleming |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Viejos Masonry Construction LLC |
veijosconstruction@gmail.com |
Owner/President |
SIOUX CITY |
Woodbury |
Iowa |
Nancy Fleming |
Jeffrey Hugh McClintock |
Signed |
762 |
2021-11-22 09:23 |
Anonymous (not verified) |
71.34.169.117 |
Oscar Lopez |
Proprietorship |
1175 Office Park Road Apt 109 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. |
2021-11-15 |
Oscar Lopez |
deb@piciowa.com |
WDM |
Polk |
ia |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Oscar Lopez |
deb@piciowa.com |
self |
WDM |
Polk |
IA |
Debra Stratton |
Kelly Denger |
Signed |
2098 |
2024-03-15 18:38 |
Anonymous (not verified) |
94.188.205.177 |
OMG Bros, LLC |
Limited Liability Partnership |
404 Ivanhoe Rd, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-03-15 |
Oscar Omar Gaytan |
og210666@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Kaden Lyle |
Jake Usher |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tristan Anthony Siebrands |
omgservices@omgbros.org |
Partner |
Waterloo |
Black Hawk |
Iowa |
Kaden Lyle |
Jake Usher |
Signed |
2090 |
2024-03-12 14:16 |
Anonymous (not verified) |
94.188.205.169 |
Oscar Sosa |
Proprietorship |
110 E Cherry St Cherokee, IA 51012 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Oscar Sosa |
oscarsosa@live.com |
Cherokee |
Cherokee |
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 |
Oscar Sosa |
Ronald Halverson |
Signed |
641 |
2021-09-17 09:16 |
Anonymous (not verified) |
72.255.121.118 |
Osman Gonzalez-Sarceno |
Proprietorship |
1403 Aspen Dr Adel, 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. |
2021-09-17 |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Des Moines |
Polk |
IA |
Melissa Bolanos |
Brianna Fuller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Owner |
Des Moines |
Polk |
Iowa |
Melissa Bolanos |
Brianna Fuller |
Signed |
1420 |
2023-01-12 13:42 |
Anonymous (not verified) |
75.162.144.157 |
Clearer Sky |
Limited Liability Company |
2305 Drake Park 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. |
2023-01-12 |
Osvaldo Mayorga Delgado |
grae1524@gmail.com |
Des Moines |
Polk |
Iowa |
Juan Manuel Mayorga Delgado |
Gloria Lorena Enamorado Guzman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Osvaldo Mayorga Delgado |
Grae1524@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Juan Manuel Mayorga Delgado |
Gloria Lorena Enamorado Guzman |
Signed |
293 |
2020-10-28 06:58 |
Anonymous (not verified) |
173.189.165.102 |
Boettcher Construction |
Proprietorship |
PO Box 482, 843 West Business 30 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
otto p boettcher |
obc32@live.com |
Lisbon |
IA |
iowa |
Barb Boettcher |
Barb Boettcher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
otto p boettcher |
obc32@live.com |
same person |
Lisbon |
IA |
iowa |
Barb Boettcher |
Barb Boettcher |
Signed |
190 |
2020-06-19 11:08 |
Anonymous (not verified) |
107.77.207.128 |
PAT Construction |
Limited Liability Company |
6007 Sw 15th ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-21 |
Pablo Aguilar Tolentino |
PATConstruction77@gmail.com |
DES MOINES |
77 |
77 |
Trisha Resendiz |
Toni Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pablo Aguilar Tolentino |
PATconstruction77@gamil.com |
owner |
DES MOINES |
77 |
77 |
Trisha Resendiz |
Toni Lopez |
Signed |
1786 |
2023-08-07 05:08 |
Anonymous (not verified) |
94.188.205.169 |
Ph Construction Limited Liability Company |
Limited Liability Company |
2643 Beaver Ave Suite 105 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. |
2023-08-07 |
Patricia Ann Hook |
patricia.diverseconstruction@gmail.com |
Des Moines |
United States |
United States |
Allen W Butts |
Kate Ridge |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Patricia Ann Hook |
patricia.diverseconstruction@gmail.com |
Self - Owner |
Des Moines |
United States |
Iowa |
Allen W Butts |
Kate Ridge |
Signed |
1849 |
2023-09-19 14:57 |
Anonymous (not verified) |
94.188.207.228 |
Iowa painting solutions llc |
Limited Liability Company |
2500 pleasant 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. |
2023-09-19 |
Patricia Davalos |
iowapaintingsolutionsllc@gmail.com |
Des Moines |
Polk |
Iowa |
Javier Rascon |
Angel Perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Iowa painting solutions llc |
iowapaintingsolutionsllc@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Javier Rascon |
Angel Perez |
Signed |
1951 |
2023-12-12 13:10 |
Anonymous (not verified) |
94.188.207.230 |
Patrick McGuinnis |
Limited Liability Company |
5697 Squire Circle, Thomson, IL 61285 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-09 |
Patrick A McGinnis |
McGinnistrucking2023@yahoo.com |
Thomson |
Carroll |
IL |
Ashleigh McGuinnis |
Kimberly Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Parick A McGunnis |
mcginnistrucking2023@yahoo.com |
Self |
Thomson |
Carroll |
IL |
Ashleigh McGinnis |
Kimberly Williams |
Signed |
1819 |
2023-08-26 00:50 |
Anonymous (not verified) |
94.188.205.177 |
JnP Enterprise LLC D/B/A/ JnP Trucking |
Limited Liability Company |
110 Elizabeth St W Grand Junction, IA. 50107 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-26 |
Patrick Cook |
pat@jnp-enterprise.com |
Grand Junction |
Iowa |
United States |
Mary J Mack |
Hayden M Cook |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Patrick Cook |
pat@jnp-enterprise.com |
50% Member, Owner, Operator |
Grand Junction |
Iowa |
United States |
Mary J Mack |
Hayden M Cook |
Signed |
1328 |
2022-10-07 22:45 |
Anonymous (not verified) |
50.82.178.112 |
Compass Commercial Services LLC |
Limited Liability Company |
1950 Boyson road, 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. |
2022-10-07 |
Patrick Roland |
mastershineservices@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Aubrey Hantz |
Brenna Trinkle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Fortanini |
bfontanini@compassbuilt.com |
Project Manager |
Hiawatha |
Linn |
Iowa |
Aubrey Hantz |
Brenna Trinkle |
Signed |
2209 |
2024-05-07 15:03 |
Anonymous (not verified) |
94.188.207.225 |
THE FURNITURE GIRL LLC |
Limited Liability Company |
19257 CONIFER LN 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. |
2024-05-07 |
PATTI WIGGINS |
pwiggins@npdodge.com |
VILLISCA |
MONTGOMERY |
IA |
NATHAN HULL |
JESSICA GARDNER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PATTI WIGGINS |
pwiggins@npdodge.com |
SELF |
VILLISCA |
MONTGOMERY |
IA |
NATHAN HULL |
JESSICA GARDNER |
Signed |
394 |
2021-02-11 13:32 |
Anonymous (not verified) |
216.51.194.37 |
Estherville Aviation, Inc. |
Limited Liability Company |
1672 425th Ave., 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. |
2021-02-11 |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Estherville |
Emmet |
Iowa |
Elizabeth Burton |
Steve Erickson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Abrams Slaughter |
estavtn@yourstarnet.net |
Owner/president |
Estherville |
Emmet |
Iowa |
Steve Erickson |
Treven Carlson |
Signed |
192 |
2020-06-24 07:42 |
Anonymous (not verified) |
66.188.136.150 |
Paul Brickley |
Proprietorship |
558 Franklin Ave. 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. |
2020-06-23 |
Paul Brickley |
kschumacher@tricorinsurance.com |
Galesburg |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Brickley |
kschumacher@tricorinsurance.com |
Same |
Galesburg |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
123 |
2020-04-16 08:33 |
Anonymous (not verified) |
159.242.36.129 |
Paul Brown |
Proprietorship |
5 Cedar Ridge CT, Ventura, IA 50482-8992 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Paul Brown |
cedars4@cltel.net |
Ventura |
Cerro Gordo |
IA |
Tom Stephany |
Amanda Korenberg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Brown |
cedars4@cltel.net |
self |
Ventura |
Cerro Gordo |
IA |
Tom Stephany |
Amanda Korenberg |
Signed |
1044 |
2022-04-13 09:11 |
Anonymous (not verified) |
166.181.81.114 |
Paul Wall Assemblies LLC |
Limited Liability Company |
38165 Belgian 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-04-13 |
Paul Carnicle |
paulcarnicle@yahoo.com |
Strawberry Point |
Iowa |
United States |
Alexander Gabriel Guthrie |
Sebastin Thompsin |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Paul Carnicle |
paulcarnicle@yahoo.com |
Partner |
Strawberry Point |
Iowa |
United States |
Alexander Gabriel Guthrie |
Sebastin Thompson |
Signed |
478 |
2021-04-14 13:18 |
Anonymous (not verified) |
65.103.82.36 |
Fortress Lock & Key LLC |
Proprietorship |
1111 w 10th 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. |
2020-02-12 |
Paul Dunn |
na@gmail.com |
Davenport |
Scott |
IA |
Jordan |
Rose |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Dunn |
na@gmail.com |
Owner |
Davenport |
Scott |
IA |
jordan |
Rose |
Signed |
1522 |
2023-03-16 15:24 |
Anonymous (not verified) |
94.188.205.175 |
Paul fausett |
Proprietorship |
1060 Ne 43rd 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. |
2023-03-16 |
Paul Edward fausett jr |
pablolow126@gmail.com |
Des Moines |
Polk |
IA |
Crista Elizabeth baires |
Paul Edward fausett sr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Edward fausett jr |
pablolow126@gmail.com |
Self |
Des Moines |
Polk |
IA |
Crista Elizabeth baires |
Paul Edward fausett sr |
Signed |
1542 |
2023-03-29 14:43 |
Anonymous (not verified) |
94.188.205.166 |
Peterson Home Improvement, LLC |
Limited Liability Company |
31451 510th Street Russell, 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. |
2023-03-28 |
Paul M Peterson |
petersonhomeimprovementllc@gmail.com |
Russell |
Lucas |
Iowa |
Peggy Jo Peterson |
Matthew Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peggy Peterson |
petersonhomeimprovementllc@gmail.com |
Husband |
Russell |
Lucas |
Iowa |
Paul M Peterson |
Matthew Peterson |
Signed |
2127 |
2024-03-29 09:50 |
Anonymous (not verified) |
94.188.205.177 |
Peterson Home Improvement, LLc |
Limited Liability Company |
31451 510th Street Russ |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Paul M Peterson |
petersonhomeimprovementllc@gmail.com |
Russell |
Iowa |
Iowa |
Peggy Jo Peterson |
Matthew Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peggy Peterson |
petersonhomeimprovementllc@gmail.com |
Husband |
Russell |
Lucas |
Iowa |
Paul M Peterson |
Matthew Peterson |
Signed |
161 |
2020-05-19 11:31 |
Anonymous (not verified) |
208.95.1.97 |
Paul McCoy DBA McCoy Contracting |
Proprietorship |
2806 Highway T47, Montour, Iowa 50173 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-19 |
Paul McCoy |
paulrmccoy1969@gmail.com |
Montour |
Tama |
Iowa |
Mike Thede |
Toni Chaska |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul McCoy |
paulrmccoy1969@gmail.com |
Owner |
Montour |
Tama |
Iowa |
Mike Thede |
Toni Chaska |
Signed |
670 |
2021-10-13 12:30 |
Anonymous (not verified) |
173.19.179.111 |
MULLER TRANSPORT LLC |
Limited Liability Company |
2083 260TH 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. |
2021-10-13 |
PAUL MULLER |
MULLERTANSPORTLLC@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PAUL MULLER |
JOEL@WALKERINSURANCEIA.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
598 |
2021-08-06 19:04 |
Anonymous (not verified) |
107.77.208.84 |
Paul Adams |
Proprietorship |
914 Bayfield drive Denton TX 76209 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-06 |
Paul T Adams |
ptadams61@yahoo.com |
Denton |
Denton |
Tx |
Jeanie Moses |
Richard Moses |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul T Adams |
ptadams61@yahoo.com |
Friends |
Milan |
Rock Island |
Illinois |
Jeanie Moses |
Richard Moses |
Signed |
1904 |
2023-11-13 09:27 |
Anonymous (not verified) |
94.188.207.224 |
Paul White |
Proprietorship |
4991 Old C Boscobel, WI 53805 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Paul White |
darrele@ciains.biz |
Boscobel |
Grant |
Wisconsin |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul White |
darrele@ciains.biz |
self |
Boscobel |
Grant |
Wisconsin |
Chris Fye |
Darrel Elsbernd |
Signed |
770 |
2021-11-22 18:17 |
Anonymous (not verified) |
192.82.97.13 |
Paul Wire |
Proprietorship |
1005 25th Street SW, 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 |
Paul Wire |
gizzmochee@gmail.com |
Spencer |
Clay |
IA |
Lori Wire |
Abigail Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Wire |
gizzmochee@gmail.com |
Self |
Spencer |
Clay |
IA |
Lori Wire |
Abigail Miles |
Signed |
1349 |
2022-10-28 12:37 |
Anonymous (not verified) |
173.26.153.59 |
spotlight drywall |
Proprietorship |
1001 7th 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. |
2022-06-01 |
paul woods |
spotlight.2008@hotmail.com |
Grundy Center |
Ia |
United States |
thuy do |
jaden do |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
thuy do |
spotlight.2008@hotmail.com |
bookeeper |
Grundy Center |
Ia |
United States |
thuy do |
jaden do |
Signed |
182 |
2020-06-11 14:18 |
Anonymous (not verified) |
173.29.64.73 |
Diamond Builders of Davenport INC |
Proprietorship |
14358 275th St, Long grove, IA 52756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Paula Woods |
paulawoods@diamond-builders.com |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Green |
tyler@porterinsuranceinc.com |
Insurance Agent |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
202 |
2020-07-10 15:30 |
Anonymous (not verified) |
50.82.95.247 |
Paulo De Oliveira |
Proprietorship |
466 Valeen In Belton, MO 64012 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-10 |
Paulo De Oliveira |
paulinhousa1981@gmail.com |
Belton |
Cass |
Missouri |
Deanna K Yersin |
Ryan S. Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paulo De Oliveira |
paulinhousa1981@gmail.com |
paulinhousa1981@gmail.com |
Belton |
Cass |
Missouri |
Deanna K Yersin |
Ryan S. Johnson |
Signed |
1558 |
2023-04-06 19:15 |
Anonymous (not verified) |
94.188.207.224 |
Bechler Services |
Limited Liability Partnership |
5244 180th Street Sibley 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. |
2023-04-06 |
Payton Bechler |
bechler.services@gmail.com |
Sibley |
Osceola |
Iowa |
Kody Koerselman |
Richard Bechler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Payton Bechler |
bechler.services@gmail.com |
Owner |
Sibley |
Osceola |
Iowa |
Kody Koerselman |
Richard Bechler |
Signed |
775 |
2021-12-02 11:40 |
Anonymous (not verified) |
65.144.174.26 |
Pedro Campos |
Proprietorship |
16901 SW 13th 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. |
2021-12-02 |
Pedro Campos |
camposp113@msn.com |
Des Moines |
Polk |
IA |
Antonio Campos |
Daniel Perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pedro Campos |
camposp113@msn.com |
Self |
Des Moines |
Polk |
Iowa |
Antonio Campos |
Daniel Perez |
Signed |
1996 |
2024-01-24 10:30 |
Anonymous (not verified) |
94.188.207.224 |
E&p quality home remodeling llc |
Limited Liability Company |
2660 NE 44th ct desmoines 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. |
2024-01-24 |
Pedro martinez |
pmsalas82@gmail.com |
Des Moines |
Polk |
Iowa |
Rogelio martinez |
Rigoberto martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pedro Martinez |
pmsalas82@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Rogelio Martínez |
Rigoberto Martínez |
Signed |
1917 |
2023-11-21 12:40 |
Anonymous (not verified) |
94.188.205.174 |
Ramos Painting LLC |
Limited Liability Company |
802 E COUNTY LINE RD #279, 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. |
2023-11-01 |
Pedro Ramos |
gcort06@gmail.com |
Des Moines |
Polk |
Iowa |
Leonel Ramos |
Jose Ramos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Pedro Ramos |
gcort06@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Leonel Ramos |
Jose Ramos |
Signed |
2057 |
2024-02-26 16:17 |
Anonymous (not verified) |
94.188.207.228 |
Pedro Salazar Trejo |
Proprietorship |
1116 18th Ave SW 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. |
2024-02-26 |
Pedro Salazar Trejo |
pedrosalazart@icolud.com |
Cedar rapids |
Linn County |
IA |
Carlos Izaguirre |
Omar Trejo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martiniano Germán Maldonado |
maldonadomartiniano675@gmail.com |
Employee |
Cedar rapids |
Linn County |
Iowa |
Carlos Izaguirre |
Omar Trejo |
Signed |
1939 |
2023-12-05 14:32 |
Anonymous (not verified) |
94.188.207.229 |
PJ Trucking Unlimited LLC |
Limited Liability Company |
2617 380th 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. |
2023-12-05 |
Peggy Jensen |
pegandhalj@gmail.com |
Farragut |
US |
IA |
Darlene |
Julie Ann Marshsll |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peggy Jensen |
pegandhalj@gmail.com |
self |
Farragut |
US |
IA |
Darlene Carpenter |
Julie Marshall |
Signed |
1845 |
2023-09-15 11:31 |
Anonymous (not verified) |
94.188.205.174 |
Penny Carlton |
Limited Liability Company |
2550 Middle Rd. Suite 300 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. |
2023-09-15 |
Penny Marie Carlton |
thrivecounselingqc@gmail.com |
Bettendorf |
Scott |
Iowa |
Anna Blanchard |
Nick Carlton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Penny Carlton |
thrivecounselingqc@gmail.com |
self, owner |
Bettendorf |
Scott |
Iowa |
Katie Flynn |
Nick Carlton |
Signed |
189 |
2020-06-16 16:24 |
Anonymous (not verified) |
173.28.58.2 |
Perry Engel |
Proprietorship |
140 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. |
2020-06-12 |
Perry Engel |
HRSolutionsContracting@gmail.com |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perry Engel |
HRSolutionsContracting@gmail.com |
Self |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
674 |
2021-10-15 09:43 |
Anonymous (not verified) |
173.29.63.3 |
Peter Hawley |
Proprietorship |
524 n galena ave, Wyoming Illinois 61491 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-15 |
Peter Anthony Hawley |
hawleypete801@gmail.com |
Wyoming |
Stark |
Illinois |
Elizabeth Doreen Hawley |
Ian Matthew Esmoil |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peter Anthony Hawley |
hawleypete801@gmail.com |
Self |
Wyoming |
Stark |
IL |
Elizabeth Doreen Hawley |
Ian Matthew Esmoil |
Signed |
2031 |
2024-02-07 10:54 |
Anonymous (not verified) |
94.188.207.224 |
PETER MARTENS |
Proprietorship |
305 4TH STREET NORTH, ALBERT CITY, IOWA 50510 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
PETER KLASSEN MARTENS |
pkmmartens@hotmail.com |
ALBERT CITY |
BUENA VISTA |
IOWA |
ROBERT EUGENE BELT |
JOHN CLARENCE OLERICH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PETER KLASSEN MARTENS |
pkmmartens@hotmail.com |
SELF |
ALBERT CITY |
SAC |
IOWA |
ROBERT EUGENE BELT |
JOHN CLARENCE OLERICH |
Signed |
545 |
2021-06-22 12:58 |
Anonymous (not verified) |
97.88.95.170 |
Peter L. Viscusi |
Proprietorship |
328 Jones Avenue, Warrensburg, MO 64093 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-22 |
Peter L. Viscusi |
pviscusi@charter.net |
Warrensburg |
Johnson |
Missouri |
Bradley S. McGuffey |
Randel C. Kyle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peter L. Viscusi |
pviscusi@charter.net |
Self |
Warrensburg |
Johnson |
Missouri |
Bradley S. McGuffey |
Randel C. Kyle |
Signed |
874 |
2022-01-30 19:13 |
Anonymous (not verified) |
199.168.106.132 |
Pete Wilcox Trenching |
Proprietorship |
714 Main Street 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. |
2022-01-29 |
Peter Wilcox |
kwilcox@cfu.net |
Cedar Falls |
Black Hawk |
Iowa |
Terri Strein |
Marlene Rasmussen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
The Accel Group LLC |
info@acceladvantage.com |
customer |
Cedar Falls |
Black Hawk |
IA |
Terri Strein |
Marlene Rasmussen |
Signed |
1556 |
2023-04-05 14:08 |
Anonymous (not verified) |
94.188.205.169 |
Capstone Staffing Solutions LLC |
Limited Liability Company |
315 E 5th St, STE 202, 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. |
2023-04-05 |
Peterson Munyasia |
pete@capstonestaffingsolutions.com |
Allen |
USA |
TX |
Daniel Mwangi |
Elizabeth Munene |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peterson Munyasia |
pete@capstonestaffingsolutions.com |
Owner |
Allen |
USA |
TX |
Daniel Mwangi |
Elizabeth Munene |
Signed |
1312 |
2022-09-17 15:29 |
Anonymous (not verified) |
97.125.242.121 |
Heartland Blinds |
Limited Liability Company |
1255 Emmons St, 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. |
2022-09-17 |
Phil Murray |
proinstallia@yahoo.com |
Hiawatha |
Linn |
IA |
Jared Metcalf-Murray |
Jeremy Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christene Murray |
chrissymurray57@yahoo.com |
Self |
Hiawatha |
Linn |
IA |
Jared Metcalf-Murray |
Jeremy Murray |
Signed |
1211 |
2022-07-18 14:10 |
Anonymous (not verified) |
172.58.85.43 |
Palomeque Gutter LLC |
Limited Liability Company |
2004 se 24th st Grimes IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-18 |
Philips Palomeque |
ecuaphilips94@gmail.com |
Des Moines IA |
USA |
Iowa |
Philips Peter Palomeque Vallejo |
Philips Palomeque |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Philips Palomeque |
ecuaphilips94@gmail.com |
Owner |
Des Moines |
USA |
Iowa |
Philips Peter Palomeque Vallejo |
Erika Zapata |
Signed |
1547 |
2023-03-30 08:45 |
Anonymous (not verified) |
94.188.207.223 |
Palomeque Gutter LLC |
Limited Liability Company |
2004 SE 24TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-30 |
Philips Palomeque |
ecuaphilips94@gmail.com |
Grimes |
USA |
IA |
Philips Palomeque |
Philips Palomeque |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Philips Palomeque |
ecuaphilips94@gmail.com |
My self |
Grimes |
USA |
Ia |
Philips Palomeque |
Philips Palomeque |
Signed |
1274 |
2022-08-19 13:34 |
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 |
Phillip Hoxsey |
phillhoxey81@gmail.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 |
1300 |
2022-09-07 16:38 |
Anonymous (not verified) |
174.198.70.216 |
Phillip Phelps |
Proprietorship |
2900 4th St 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. |
2022-09-07 |
Phillip Phelps |
phillipphelps8732@yahoo.com |
Marion |
Linn |
Iowa |
Kaitlin Davidson |
Kevin Phelps |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Phillip Phelps |
phillipphelps8732@yahoo.com |
Self |
Marion |
Linn |
Iowa |
Kaitlin Davidson |
Kevin Phelps |
Signed |
1195 |
2022-07-08 13:24 |
Anonymous (not verified) |
174.198.67.66 |
Chapas Construction |
Limited Liability Company |
6424 Roseland 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. |
2022-07-08 |
Polibio Raul Chapa Farez |
chapasconstructionllc@gmail.com |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Polibio Raul Chapa |
chapasconstructionllc@gmail.com |
President |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
1805 |
2023-08-17 10:00 |
Anonymous (not verified) |
94.188.207.229 |
Polly Pattison Sewing LLC |
Limited Liability Company |
6917 New York Ave. 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. |
2023-08-17 |
Polly Pattison |
pollypattison@msn.com |
Urbandale |
Polk |
IA |
Lynn Niceswanger |
Louise Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Polly Pattison |
pollypattison@msn.com |
Same |
Urbandale |
Polk |
Iowa |
Lynn Niceswanger |
Louise Anderson |
Signed |
1891 |
2023-11-02 06:24 |
Anonymous (not verified) |
94.188.207.225 |
DOC Services |
Proprietorship |
3313 , E 7th 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 |
Quentin Ferguson |
1quensy@gmail.com |
Des Moines |
Polk |
IA |
Dione Fergsuon |
Quensy Ferguson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Quentin Ferguson |
1quensy@gmail.com |
Self |
Des Moines |
Polk |
Ia |
Dione Ferguson |
Quensy Ferguson |
Signed |
948 |
2022-03-04 13:23 |
Anonymous (not verified) |
71.28.216.129 |
Zack & Rachael Bushman |
Proprietorship |
321 Countryside Dr, 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. |
2022-03-04 |
Rachael Bushman |
rachaelnessa@yahoo.com |
Waukon |
Allamakee |
IA |
Zack Bushman |
Doyle Wegner |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Zack Bushman |
rachaelnessa@yahoo.com |
Owner Operator |
Waukon |
Allamakee |
IA |
Rachael Bushman |
Doyle Wegner |
Signed |
170 |
2020-06-01 13:31 |
Anonymous (not verified) |
173.28.28.57 |
Rachel Poppens |
Proprietorship |
910 Parriott Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-19 |
Rachel Poppens |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rachel Poppens |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
224 |
2020-08-05 13:25 |
Anonymous (not verified) |
173.28.28.57 |
Shear Beautique Retail, LLC |
Limited Liability Company |
910 Parriott, 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. |
2020-07-28 |
Rachel Poppens |
cmins_re@mchsi.com |
Allison |
Butler |
Iowa |
Thomas R Poppens |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rachel Poppens |
cmins_re@mchsi.com |
Self |
Allison |
Butler |
Iowa |
Thomas R Poppens |
Roxanne Kolder |
Signed |
210 |
2020-07-20 13:28 |
Anonymous (not verified) |
75.162.95.97 |
RM construction |
Proprietorship |
65 SE 5TH STREET APT 4 DES MOINES IA . 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-20 |
Rafael Marquez |
marquezrafael1@outlook.com |
Des Moines |
Polk IOWA |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rafael Marquez |
marquezrafael1@outlook.com |
owner |
Des Moines |
Polk |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
146 |
2020-05-01 05:34 |
Anonymous (not verified) |
174.217.5.175 |
Five Nail Services |
Limited Liability Company |
32379 162nd 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. |
2020-05-01 |
Ralph Chiodo |
rchiodo2@gmail.com |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ralph Chiodo |
rchiodo2@gmail.com |
Self |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
75 |
2020-02-24 15:03 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Ramiro Jurado Bucio |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
74 |
2020-02-24 15:00 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Ramiro Jurado Gomez |
Liberty21424@gmail.com |
Des Moines |
Polk |
IA |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
2200 |
2024-05-06 08:46 |
Anonymous (not verified) |
94.188.207.226 |
Dominguez Construction LLC |
Limited Liability Company |
1680 East Emma 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. |
2024-05-05 |
Ramon Dominguez |
3memincolina@gmail.com |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Stacey Lazear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ramon Dominquez |
3memincolina@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Nathan Miller |
Stacey Lazear |
Signed |
1915 |
2023-11-21 04:06 |
Anonymous (not verified) |
94.188.207.225 |
Advanced Foam Systems |
Limited Liability Company |
1378 Midway Ave 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. |
2023-11-18 |
Randy Block |
advancedfoamsystems@yahoo.com |
Tripoli |
Bremer |
Iowa |
Linda Block |
Brady Block |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy Block |
advancedfoamsystems@yahoo.com |
Me |
Tripoli |
Bremer |
Iowa |
Linda block |
Brady block |
Signed |
843 |
2022-01-20 07:48 |
Anonymous (not verified) |
207.199.230.75 |
Heart of Iowa Inspections LLC |
Limited Liability Company |
2700 Highway 63 Oskaloosa, Iowa 52577 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Randy DeHeer |
rdenheer2828@gmail.com |
Oskaloosa |
Mahaska |
Iowa |
Cheryl Brown |
Doris Crile |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy DeHeer |
rdenheer2828@gmail.com |
self |
Oskaloosa |
Mahaska |
Iowa |
Cheryl Brown |
Doris Crile |
Signed |
934 |
2022-02-23 12:13 |
Anonymous (not verified) |
207.199.230.75 |
Randy DeHeer |
Limited Liability Company |
2700 Highway 63 Oskaloosa, Iowa 52577 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Randy DeHeer |
rdeheer2828@gmail.com |
Oskaloosa |
Mahaska |
Jowa |
Cheryl Brown |
Doris Crile |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy DeHeer |
rdeheer2828@gmail.com |
Self |
Oskaloosa |
Mahaska |
Iowa |
Cheryl Brown |
Doris Crile |
Signed |
1961 |
2023-12-16 12:22 |
Anonymous (not verified) |
94.188.207.228 |
Randy Hove |
Proprietorship |
2376 370th St. Jewell. Iowa. 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. |
2023-12-14 |
Randy Gordon Hove |
mandrhove@gmail.com |
Jewell |
Hamilton |
Iowa |
Ryan Drzycimski |
Casey Westling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy |
mandrhove@gmail.com |
Same |
Same |
Same |
Same |
Same |
Same |
Signed |
1355 |
2022-11-01 11:06 |
Anonymous (not verified) |
23.252.149.120 |
Randy J. Hackenmiller dba Hackenmiller Trucking |
Proprietorship |
606 Grain Millers Dr. PO Box 125, St. Ansgar, IA 50472-0125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Randy J. Hackenmiller |
randhack@myomnitel.com |
St. Ansgar |
Mitchell |
Iowa |
Kent A. Wilder |
Rebecca L. Dobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy J. Hackenmiller |
randhack@myomnitel.com |
Self |
St. Ansgar |
Mitchell |
Iowa |
Kent A. Wilder |
Rebecca L. Dobson |
Signed |
1807 |
2023-08-17 12:45 |
Anonymous (not verified) |
94.188.205.175 |
LONE STAR ROOFING, LLC |
Limited Liability Company |
4021 WINDSOR 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. |
2023-08-17 |
RAQUEL B DIAZ MENENDEZ |
LONE.STAR.ROOFING76@GMAIL.COM |
DES MOINES |
USA |
IOWA |
LILIANA SANCHEZ |
RENE ALEXANDER VELASCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LONE STAR ROOFING, LLC |
LONE.STAR.ROOFING76@GMAIL.COM |
MEMBER OWNER |
DES MOINES |
USA |
IOWA |
LILIANA SANCHEZ |
RENE ALEXANDER VELASCO |
Signed |
69 |
2020-02-19 15:58 |
Anonymous (not verified) |
198.14.241.59 |
MORENOS C ROOFING LLC |
Limited Liability Company |
2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
RAQUEL OLEA CAMACHO |
JORGETREJO19896@GMAIL.COM |
IOWA CITY |
JOHNSON |
IOWA |
JORGE TREJO |
JOSE SALGADO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RAQUEL OLEA CAMACHO |
JORGETREJO19896@GMAIL.COM |
OWNER |
IOWA CITY |
JOHNSON |
IOWA |
JORGE TREJO |
JOSE SALGADO |
Signed |
1980 |
2024-01-10 11:32 |
Anonymous (not verified) |
94.188.207.224 |
Raudel Correa |
Proprietorship |
1924 23rd 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. |
2024-01-02 |
Raudel Correa |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Martin Pinon |
Debra Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raudel Correa |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Martin Pinon |
Debra Stratton |
Signed |
1672 |
2023-06-01 15:16 |
Anonymous (not verified) |
94.188.207.224 |
Raudel Correa Correa |
Proprietorship |
1924 23rd 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. |
2023-06-01 |
Raudel Correa Correa |
correaraudel6@gmail.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raudel Correa Correa |
correaraudel6@gmail.com |
self |
DM |
Polk |
IA |
Den Stratton |
Kelly Denger |
Signed |
1285 |
2022-08-26 08:22 |
Anonymous (not verified) |
97.125.43.203 |
Raul Villanueva |
Proprietorship |
6901 SE 14th #71 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Raul Villanueva |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raul Villanueva |
deb@picowa.com |
self |
Des Moines |
Polk |
IA |
Debra Stratton |
Kelly Denger |
Signed |
1650 |
2023-05-16 12:06 |
Anonymous (not verified) |
94.188.207.225 |
R & J Transport |
Proprietorship |
85152 US HWY 81 PIERCE NE 68767 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Ray Tom Clausen III |
jamieleabeutler2013@gmail.com |
Pierce |
NE |
United States |
Jamie Clausen |
Ann Siebrandt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ray T Clausen III |
jamieleabeutler2013@gmail.com |
Owner |
Pierce |
Pierce |
Ne |
Jamie Clausen |
Ann Siebrandt |
Signed |
1484 |
2023-02-25 16:42 |
Anonymous (not verified) |
94.188.205.177 |
Carpenter wood shed/ rays longging |
Limited Liability Company |
1631 230th 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. |
2023-02-27 |
Raymond Carpenter |
corinnafrymoyer@gmail.com |
tipton |
Cedar |
Iowa |
corinna frymoyer |
Levi carpenter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raymond Carpenter |
corinnafrymoyer@gmail.com |
Self |
Tipton |
Cedar |
Iowa |
Corinna frymoyer |
Levi carpenter |
Signed |
1860 |
2023-10-04 14:31 |
Anonymous (not verified) |
94.188.207.229 |
Raymond Osbon |
Proprietorship |
1634 Park Towne 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. |
2023-10-04 |
Raymond Earl Osbon |
rozbon999@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Brandon Gibbs |
Jamie Fisher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raymond Earl Osbon |
rozbon999@gmail.com |
Myself |
Cedar Rapids |
Linn |
Iowa |
Brandon Gibbs |
Jamie Fisher |
Signed |
827 |
2022-01-10 16:36 |
Anonymous (not verified) |
167.142.141.89 |
Hill Lawn Care |
Proprietorship |
2307 Campbell Dr 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. |
2022-01-10 |
Raymond Hill |
rayhill_19@hotmail.com |
Marshalltown |
Marshall |
Iowa |
Kaitlyn Schuring |
Matt Gannaway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raymond Hill |
rayhill_19@hotmail.com |
Self |
Marshalltown |
Marshall |
Iowa |
Kaitlyn Schuring |
Matt Gannaway |
Signed |
25 |
2020-01-03 13:09 |
Anonymous (not verified) |
74.84.121.206 |
Raymond Jones |
Proprietorship |
P O Box 682 Monona IA 52159 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-29 |
Raymond Jones |
darrele@ciains.biz |
Monona |
Clayton |
Iowa |
Darrel J Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel J Elsbernd |
darrele@ciains.biz |
insurance agent |
Lime Springs |
Howard |
Iowa |
Darrel J Elsbernd |
Chris Fye |
Signed |
1491 |
2023-03-03 11:24 |
Anonymous (not verified) |
94.188.207.224 |
Ray gist |
Proprietorship |
4330 nw 9th 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. |
2023-03-03 |
Raymond Rex Gist |
rrgist8@yahoo.com |
Dsm |
Polk |
Ia |
Amber Gist |
Victor Brawdy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Raymond Rex Gist |
rrgist8@yahoo.com |
Same person |
Dsm |
Polk |
Ia |
Amber Gist |
Victor Brawdy |
Signed |
66 |
2020-02-19 08:48 |
Anonymous (not verified) |
170.232.227.246 |
CRS Inc |
Proprietorship |
1442 3rd Ave SW Belmond, IA 50421 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
Rebecca Gardner |
beckygard1018@gmail.com |
Waverly |
Bremer |
Iowa |
Sarah Lowe |
Kelsey Poe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rebecca Gardner |
beckygard1018@gmail.com |
Consultant |
Waverly |
Bremer |
Iowa |
Sarah Lowe |
Kelsey Poe |
Signed |
734 |
2021-11-11 14:05 |
Anonymous (not verified) |
72.13.16.172 |
REDFEARN TRUCKING INC |
Proprietorship |
5512 WEST STAGECOACH TRAIL |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-18 |
REDFEARN TRUCKING INC |
dave@allseasonstrucking.com |
GALENA |
JODAVIES |
IL |
DAVE NEUWOHNER |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
REDFEARN TRUCKING INC |
dave@allseasonstrucking.com |
PRESIDENT |
GALENA |
JODAVIES |
IL |
DAVE NEUWOHNER |
BEN MOYER |
Signed |
1576 |
2023-04-17 08:32 |
Anonymous (not verified) |
94.188.205.167 |
Reece Wilson |
Limited Liability Company |
1431 Starbeck Circle |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-14 |
Reece J Wilson |
rjwilson030@gmail.com |
Cedar Falls |
Blackhawk |
Iowa |
Kendall Cotant |
Darryl Mason |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Richter |
jrichter@beecherlaw.com |
Business |
Waterloo |
Blackhawk |
Iowa |
Kendall Cotant |
Jared Hottle |
Signed |
1679 |
2023-06-06 08:27 |
Anonymous (not verified) |
94.188.205.174 |
Remys Drywall LLC |
Proprietorship |
42 Hoover Blvd 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. |
2023-06-06 |
Remigio M Juan |
remmateojuan1997@gmail.com |
West Branch |
Cedar |
IA |
Brad Bower |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Remigio M Juan |
remmateojuan1997@gmail.com |
Self |
West Branch |
Cedar |
IA |
Brad Bower |
Chris Hay |
Signed |
1099 |
2022-05-13 12:17 |
Anonymous (not verified) |
75.162.66.90 |
EMPIRE CONTRACTORS, LLC |
Limited Liability Company |
8415 FRANKLIN AVE APT 18 CLIVE, IOWA 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. |
2022-05-13 |
RENE ALEXANDER VELASCO |
velasco.alexander@yahoo.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez Gutierrez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RENE ALEXANDER VELASCO |
velasco.alexander@yahoo.com |
OWNER |
DES MOINES |
USA |
IOWA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
1102 |
2022-05-13 13:13 |
Anonymous (not verified) |
75.162.173.244 |
EMPIRE CONTRACTORS, INC |
Proprietorship |
8415 FRANKLIN AVE APT 18 CLIVE, IOWA 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. |
2022-05-13 |
RENE ALEXANDER VELASCO |
velasco.alexander@yahoo.com |
DES MOINES |
USA |
IOWA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RENE ALEXANDER VELASCO |
velasco.alexander@yahoo.com |
COMPANY OWNER |
DES MOINES |
USA |
IOWA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
1864 |
2023-10-09 09:52 |
Anonymous (not verified) |
94.188.207.223 |
Admiral Staffing Inc |
Limited Liability Company |
580 8th Ave, 15th Floor, New York NY 10018 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-09 |
Rezwan Rafeek |
ray@admiralstaffinginc.com |
23 Catalpa Lane |
Valley Stream |
NY |
Ikbal Sherif |
Salim Balee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shafi Rafeek |
shafi@admiralstaffinginc.com |
Office Manager |
New York |
NY |
United States |
Ikbal Sherif |
Salin Balee |
Signed |
1826 |
2023-08-30 16:38 |
Anonymous (not verified) |
94.188.207.227 |
IOWA MOLD REMOVAL |
Limited Liability Company |
103 15TH ST SW, ALTOONA, IA 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-30 |
RHETT OSELETTE |
RHETT.OSELETTE@GMAIL.COM |
CLIVE |
DALLAS |
IOWA |
ELLA OSELETTE |
MYA OSELETTE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KATIE BROWN |
KATIE@IOWAMOLDREMOVAL.COM |
EMPLOYER |
ALTOONA |
POLK |
IOWA |
MYA OSELETTE |
ELLA OSELETTE |
Signed |
1633 |
2023-05-09 15:46 |
Anonymous (not verified) |
94.188.205.168 |
Unique Painting, LLC |
Partnership |
2500 E. 39Th 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. |
2023-05-09 |
Ricardo Rodriguez Perfecto |
uniquepainting00@gmail.com |
Des Moines |
USA |
IOWA |
Oseas Diaz |
Jorge Corona |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ricardo Rodriguez Perfecto |
uniquepainting00@gmail.com |
Vice president |
Des Moines |
USA |
IOWA |
Oseas Diaz |
Jorge Corona |
Signed |
1293 |
2022-09-03 08:03 |
Anonymous (not verified) |
50.82.244.98 |
MTZ Drywall |
Proprietorship |
1101 Eighth 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. |
2022-09-02 |
Richar Martinez |
menace_42@icloud.com |
West Des Moines |
United States |
Iowa |
Alejandro Gonzalez |
Emilio Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Jenkins |
jjenkins@farmersagent.com |
N/A |
Urbandale |
United States |
Iowa |
Alejandro Gonzalez |
Emilio Martinez |
Signed |
2145 |
2024-04-11 12:27 |
Anonymous (not verified) |
94.188.205.177 |
Grinnell Web Services LLC |
Limited Liability Company |
1902 Spring St, Grinnell IA 50112 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-11 |
Richard Ethington |
RDE326@rrmse.com |
Grinnell |
Poweshiek |
Iowa |
Lori Stratton |
Lisa Folkmann |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Ethington |
rde326@rrmse.com |
self |
Grinnell |
poweshiek |
iowa |
lori stratton |
lisa folkmann |
Signed |
413 |
2021-02-24 16:21 |
Anonymous (not verified) |
199.120.93.40 |
Nelson Tire Recycling LLC |
Limited Liability Company |
2270 Farley Rd Cascade Iowa 52033 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-02-24 |
Richard A Nelson |
nelsontirerecycling@gmail.com |
Cascade |
Dubugue |
Iowa |
Wendy Bergfeld |
Jan Elhinger |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Richard |
nelsontirerecycling@gmail.com |
Owner/officer |
Cascade |
Dubugue |
Iowa |
Wendy Bergfeld |
Jan Ehlinger |
Signed |
1396 |
2022-12-19 18:35 |
Anonymous (not verified) |
174.198.65.20 |
Flyover Productions LLC |
Limited Liability Company |
300 S Clinton 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. |
2022-12-19 |
Richard A Redfern |
richredfern3@gmail.com |
Iowa City |
IA |
United States |
Susan Redfern |
Aditi Reddy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Redfern |
richredfern3@gmail.com |
Owner of company |
Iowa City |
Iowa |
United States |
Susan Redfern |
Aditi Reddy |
Signed |
2058 |
2024-02-26 16:32 |
Anonymous (not verified) |
94.188.207.224 |
performance gutter |
Proprietorship |
PO BOX 306, 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. |
2024-02-26 |
RICHARD BAINTER |
RWBNJ50@AOL.COM |
NORWALK |
WARREN |
IOWA |
DYLAN LANE |
JAMES LANE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICHARD BAINTER |
RWBNJ50@AOL.COM |
OWNER |
NORWALK |
WARREN |
IOWA |
DYLAN LANE |
JAMES LANE |
Signed |
1534 |
2023-03-27 08:16 |
Anonymous (not verified) |
94.188.205.167 |
Richatd Deist |
Proprietorship |
1445 Hwy 71 Audubon IA 50025 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-26 |
Richard Deist |
deistfarms@hotmail.com |
Audubon |
IA |
United States |
Tara Deist |
Pat Groth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bob Miller |
bob.miller@millerhybrids.com |
seed dealer |
Kalona ,Ia |
Washington |
IA |
Tara Deist |
Pat Groth |
Signed |
1535 |
2023-03-27 09:40 |
Anonymous (not verified) |
94.188.205.167 |
Richard Deist |
Proprietorship |
1445 hwy 71 Audubon Ia 50025 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-26 |
Richard Deist |
deistfarms@hotmail.com |
Audubon |
Audubon |
IA |
Tara Deist |
Pat Groth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bob Miller |
bob.miller@millerhybrids.com |
Seed dealer |
Kalona |
Washington |
IA |
Tara Deist |
Pat Groth |
Signed |
150 |
2020-05-06 10:59 |
Anonymous (not verified) |
76.190.229.163 |
RNR Holdings LLC |
Limited Liability Company |
4330 Winter Eagle Trail SE Apt B, Iowa City, Iowa 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-06 |
Richard E. White |
rwhite245@yahoo.com |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard E White |
rwhite245@yahoo.com |
Owner |
Hermitage |
Mercer |
Pennsylvania |
Gene Bell |
Victor J Veltri |
Signed |
1045 |
2022-04-13 09:55 |
Anonymous (not verified) |
192.119.237.126 |
BARGAIN HOUSE |
Proprietorship |
11 S FREDERICK AVE, OELWEIN, IA 50662 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-13 |
RICHARD M. BECKER |
SHELBY@CIOIA.COM |
HAZLETON |
BUCHANAN |
IOWA |
SHELBY S. WILLIAMS |
BOBBIE J. BERGAN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICHARD M. BECKER |
SHELBY@CIOIA.COM |
OWNER |
OELWEIN |
FAYETTE |
IOWA |
SHELBY S. WILLIAMS |
BOBBIE J. BERGAN |
Signed |
776 |
2021-12-03 10:26 |
Anonymous (not verified) |
192.230.128.72 |
Richard Makohoniuk |
Proprietorship |
785 SE Walnut Ridge 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. |
2021-12-03 |
Richard Makohoniuk |
111@mchsi.com |
Waukee |
Dallas |
Iowa |
Tara Makohoniuk |
Richard Makohoniuk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Makohoniuk |
111@mchsi.com |
Self |
Waukee |
Dallas |
IA |
Tara Makohoniuk |
Richard Makohoniuk |
Signed |
1256 |
2022-08-15 13:22 |
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. |
2022-08-08 |
Richard Miller |
rmiller0574@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 |
1028 |
2022-04-02 11:01 |
Anonymous (not verified) |
174.198.64.100 |
Great-Dain Htg/Ac & Plumbing |
Proprietorship |
1616 Maple Rd. Harlan, Iowa 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. |
2022-04-02 |
Richard Nee |
great-dain@hotmail.com |
Harlan |
Shelby |
Iowa |
Doug Clark |
Jesse Nee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Nee |
great-dain@hotmail.com |
Self |
Harlan |
Shelby |
Iowa |
Doug Clark |
Jesse Nee |
Signed |
856 |
2022-01-26 13:44 |
Anonymous (not verified) |
69.63.16.2 |
Rick Peterson |
Proprietorship |
3366 Lynden Heights Rd 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. |
2022-01-26 |
Richard Peterson |
insurancecommercialsam@greenstate.org |
Iowa City |
Johnson |
Iowa |
Jonathan Gonzalez |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Peterson |
insurancecommercialsam@greenstate.org |
Owner |
Iowa City |
Johnson |
IA |
Jonathan Gonzalez |
Dyan Kriener |
Signed |
1425 |
2023-01-18 15:20 |
Anonymous (not verified) |
174.228.35.74 |
Great-Dain Htg/Ac & Plumbing |
Proprietorship |
1616 Maple Rd Harlan, Iowa 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. |
2023-01-18 |
Richard Presly Nee |
great-dain@hotmail.com |
Harlan |
Shelby |
IA |
Theresa Clark |
Jesse Nee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Presley Nee |
great-dain@hotmail.com |
Self |
Harlan |
Shelby |
IA |
Theresa Clark |
Jesse Nee |
Signed |
689 |
2021-10-25 14:38 |
Anonymous (not verified) |
107.197.114.249 |
Brookstin Flooring LLC |
Limited Liability Company |
1702 Brown Deer Rd Coralville IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-10-25 |
Richard T Klemesrud |
rickklemesrud@gmail.com |
CORALVILLE |
IA |
United States |
Brian Woods |
Sherry Woods |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Richard T Klemesrud |
rickklemesrud@gmail.com |
Myself / Owner |
CORALVILLE |
IA |
United States |
Brian Woods |
Sherry Woods |
Signed |
323 |
2020-11-19 10:55 |
Anonymous (not verified) |
174.192.67.61 |
Connor trucking |
Proprietorship |
2791 270th st Dewitt 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. |
2020-11-19 |
Richard Todd Connor |
connortrucking@hotmail.com |
Dewitt |
Clinton |
Iowa |
Michelle Connor |
Josh connor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Richard Todd Connor |
connortruckin@hotmail.com |
Self |
Dewitt |
Clinton |
Iowa |
Michelle Connor |
Josh Connor |
Signed |
716 |
2021-11-05 13:22 |
Anonymous (not verified) |
209.252.172.87 |
Rick Clifford Clifford Custom Tile & Flooring |
Proprietorship |
1563 Palmer Ct NE, 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. |
2020-09-24 |
Rick Clifford |
cliffordcustomtile@gmail.com |
Solon |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Clifford Clifford Custom Tile & Flooring |
cliffordcustomtile@gmail.com |
Self Employed |
Solon |
Johnson |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
562 |
2021-07-08 09:46 |
Anonymous (not verified) |
66.188.136.150 |
Rick Davis |
Proprietorship |
521 N 13th St. Salina, KS 67401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Rick Davis |
kschumacher@tricorinsurance.com |
Salina |
Saline |
KS |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Davis |
kschumacher@tricorinsurance.com |
Same |
Salina |
Saline |
KS |
Mitch Kemp |
Shuree Behr |
Signed |
1930 |
2023-12-01 10:20 |
Anonymous (not verified) |
94.188.207.227 |
TriCounty Enterprises/ DeNeve Construction |
Limited Liability Company |
5527 Crane Lane 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. |
2023-12-01 |
Rick Delayne Primmer |
rdprimmerroofing@gmail.com |
Walker |
Linn |
Iowa |
Jerry Wiltsey |
Robert Null |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Delayne Primmer |
rdprimmerroofing@gmail.com |
Worker |
Walker |
Iowa |
Iowa |
Jerry Wiltsey |
Robert Null |
Signed |
767 |
2021-11-22 16:42 |
Anonymous (not verified) |
63.229.189.35 |
Lakes Custom Bath |
Proprietorship |
3721 Ithaca Avenue, 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 |
Rick Dykshoorn |
abigail@rickmilesartisans.com |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Dykshoorn |
abigail@rickmilesartisans.com |
Self |
SPIRIT LAKE |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
720 |
2021-11-05 13:57 |
Anonymous (not verified) |
209.252.172.87 |
Rick Klemesrud Brookstin Flooring |
Proprietorship |
Coralville, Ia 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-23 |
Rick Klemesrud |
installation@bachmeiercarpetone.com |
Coralville |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Klemesrud |
installation@bachmeiercarpetone.com |
Self |
Croalville |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
918 |
2022-02-16 14:23 |
Anonymous (not verified) |
172.58.22.152 |
RICK MYSAK LLC |
Limited Liability Company |
2220 GREY WOLF, 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. |
2022-02-16 |
RICK MYSAK |
camysak@gmail.com |
Hiawatha |
LINN |
IOWA |
Carrie Mysak |
RICK DeNEVE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICK MYSAK |
camysak@gmail.com |
SELF |
Hiawatha |
LINN |
IOWA |
Carrie Mysak |
RICK DeNEVE |
Signed |
1327 |
2022-10-06 12:23 |
Anonymous (not verified) |
71.39.227.238 |
RICK OBEREMBT |
Proprietorship |
1702 SYCAMORE ST, DALLAS CNETER, 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. |
2022-10-05 |
RICK OBEREMBT |
werock83@gmail.com |
DALLAS CENTER |
DALLAS |
IOWA |
ABBEY LUELLEN |
DON RICHARDSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICK OBEREMBT |
werock83@gmail.com |
SELF |
DALLAS CENTER |
DALLAS |
IOWA |
ABBEY LUELLEN |
DON RICHARDSON |
Signed |
369 |
2021-01-22 10:02 |
Anonymous (not verified) |
66.188.136.150 |
Rick Swaney |
Proprietorship |
1551 Persimmon, Stilwell, OK 74960 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-22 |
Rick Swaney |
kschumacher@tricorinsurance.com |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Swaney |
kschumacher@tricorinsurance.com |
Same |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
741 |
2021-11-11 15:09 |
Anonymous (not verified) |
72.13.16.172 |
RICK VANGORDER |
Proprietorship |
2549 QUASQUETON DIAGONAL 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. |
2019-11-18 |
RICK VANGORDER |
dave@allseasonstrucking.com |
INDEPENDENCE |
BUCHANAN |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICK VANGORDER |
dave@allseasonstrucking.com |
PRESIDENT |
INDEPENDENCE |
BUCHANAN |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
1173 |
2022-06-27 14:44 |
Anonymous (not verified) |
162.253.44.28 |
Hardwood Design Co LLC |
Limited Liability Company |
75 Commercial Drive North Liberty Iowa 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-17 |
Rilen Carew |
hardwooddesignllc@gmail.com |
Coralville |
Johnson |
Iowa |
Joan Tobin |
Olivia Meier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Fisher |
hardwooddesignllc@gmail.com |
other member of LLC |
Coralville |
Johnson |
Iowa |
Joan Tobin |
Olivia Meier |
Signed |
1165 |
2022-06-23 09:28 |
Anonymous (not verified) |
74.84.106.106 |
Rita Littrell |
Proprietorship |
620 N. 9th St., 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. |
2022-06-23 |
Rita Littrell |
ritaf1966@gmail.com |
Carlisle |
Warren |
Iowa |
Kimberly Owens |
Tina Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rita Littrell |
ritaf1966@gmail.com |
Self |
Carlisle |
Warren |
Iowa |
Kimberly Owens |
Tina Owens |
Signed |
860 |
2022-01-27 11:31 |
Anonymous (not verified) |
69.63.16.2 |
Dreams 2 Reality Construction LLC |
Limited Liability Company |
17615 Meredith Dr, Waukee, IA 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-26 |
Rob Rubsam |
rob@dreams2reality.us |
Waukee |
Dallas |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rob Rubsam |
rob@dreams2reality.us |
Member |
Waukee |
Dallas |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
1067 |
2022-04-23 11:17 |
Anonymous (not verified) |
166.181.82.231 |
Black Squirrel Siding LLC. |
Limited Liability Partnership |
1512 north 1st ave 203s |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-23 |
Robby Bartosh |
zodzoey19@gmail.com |
Cedar Rapids |
IA |
United States |
Phoenix Bartosh |
Elijah Irish |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremiah Petsche |
Blacksquirrelsiding@gmail.com |
business partner |
coralville |
johnson |
iowa |
Phoenix Bartosh |
Elijah Irish |
Signed |
368 |
2021-01-21 15:12 |
Anonymous (not verified) |
97.125.235.64 |
R. A. Snow Removals, Inc |
Proprietorship |
525 7th St NW, 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. |
2021-01-21 |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
Altoona |
Polk |
Iowa |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Aaron Snow |
rasnowremovals.inc@gmail.com |
President |
Altoona |
IA |
United States |
Shannon Keely Moses |
Jessy James Dentler |
Signed |
240 |
2020-08-23 15:03 |
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 |
Robert Alan Roths |
robrothsrams@yahoo.com |
Garner |
Hancock |
Iowa |
Ashley S Wellik |
Joshua P. Wellik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Paul Wellik |
wellikandsons@gmail.com |
contractor |
Garner |
Hancock |
Iowa |
Ashley S Wellik |
Joshua P Wellik |
Signed |
326 |
2020-11-25 08:39 |
Anonymous (not verified) |
66.188.136.150 |
Robert Barbaris |
Proprietorship |
1104 8th St SE, Cedar Rapids, IA 52401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-25 |
Robert Barbaris |
kschumacher@tricorinsurance.com |
Cedar Rapids |
Linn |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Barbaris |
kschumacher@tricorinsurance.com |
Same |
Cedar Rapids |
Linn |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
1081 |
2022-04-29 11:28 |
Anonymous (not verified) |
173.18.22.217 |
CB's Tree & Lawn Service |
Limited Liability Company |
593 25th Place Swan IA 50252 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Robert Beau Wittkowski |
robertwittkowski1@gmail.com |
Swan |
Marion |
Iowa |
Lesa Reeves |
William Schuldt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Beau Wittkowski |
robertwittkowski1@gmail.com |
Owner |
Swan |
Marion |
Iowa |
Lesa Reeves |
William Schuldt |
Signed |
2027 |
2024-02-07 09:24 |
Anonymous (not verified) |
94.188.207.228 |
RB SIDING |
Proprietorship |
P.O. BOX 2034, 310 370TH STREET, LAKE VIEW, IOWA 51450 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
ROBERT BELT |
bridgetbelt1971@outlook.com |
SELF |
SAC |
IOWA |
JOHN CLARENCE OLERICH |
NEIL THIESSEN MARTENS |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ROBERT EUGENE BELT |
bridgetbelt1971@outlook.com |
SELF |
LAKE VIEW |
SAC |
IOWA |
JOHN CLARENCE OLERICH |
NEIL THIESSEN MARTENS |
Signed |
1686 |
2023-06-12 07:45 |
Anonymous (not verified) |
94.188.207.229 |
Robert Burman |
Proprietorship |
400 Lindale Dr 119 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. |
2023-06-11 |
Robert Burman |
robertburman791@gmail.com |
Marion |
Linn |
Iowa |
Charles Wood |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Charles Wood |
Jordan loyd |
Signed |
1326 |
2022-10-04 10:27 |
Anonymous (not verified) |
70.96.153.153 |
Bright Fame Inc |
Limited Liability Company |
2185 NW 149th St, Clive, IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-04 |
Robert Ferguson |
robert@optionsexteriors.com |
Clive |
Dallas |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Ferguson |
robert@optionsexteriors.com |
Owner/Self |
Clive |
Dallas |
Iosa |
Charlotte Rasmussen |
Austin Miller |
Signed |
444 |
2021-03-22 16:26 |
Anonymous (not verified) |
207.191.204.10 |
Robert G. Wright Jr, |
Proprietorship |
2721 Elm St Dubuque, IA 52001 PO Box 475 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. |
2021-03-20 |
Robert G. Wright Jr, |
robertw1963@gmail.com |
Dubuque |
Dubuque |
Iowa |
Brian Kregal |
Lynda Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert G. Wright Jr, |
robertw1963@gmail.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Brian Kregel |
Lynda Howell |
Signed |
1273 |
2022-08-19 10:40 |
Anonymous (not verified) |
75.162.65.221 |
Robert Kilgore |
Proprietorship |
2404 34th St Des Moines 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. |
2022-08-19 |
Robert Kilgore |
robertkilgore1969@gmail.com |
Des Moines |
Polk |
Iowa |
Randy Lacine |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Kilgore |
robertkilgore1969@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
652 |
2021-09-22 21:52 |
Anonymous (not verified) |
209.152.66.250 |
Robert Stutzman |
Limited Liability Company |
33784 Hwy 22 Keota, IA 25548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
Robert L Stutzman |
bnbstutzman@gmail.com |
Keota |
Keokuk |
Iowa |
Jo Edgington |
Amber Gent |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sandra K Stutzman |
iafarmgirl90@gmail.com |
Daughter |
Keota |
Keokuk |
Iowa |
Jo Edgington |
Amber Gent |
Signed |
855 |
2022-01-26 10:39 |
Anonymous (not verified) |
209.152.66.250 |
Robert L Stutzman |
Limited Liability Company |
33784 Hwy 22 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-26 |
Robert L Stutzman |
bnbstutzman@gmail.com |
Keota |
Iowa |
United States |
Dasha Hesseltine |
Janette Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sandra Stutzman |
iafarmgirl90@gmail.com |
Daughter |
Keota |
Iowa |
United States |
Dasha Hesseltine |
Janette Miller |
Signed |
1235 |
2022-08-01 17:22 |
Anonymous (not verified) |
129.222.1.151 |
KRG Gutters |
Limited Liability Company |
20376 Whiskey Rdg 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. |
2022-08-01 |
Robert M Galey |
rsgaley24@yahoo.com |
Ottumwa |
IA |
United States |
Stacey Galey |
Kinnick Galey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert M Galey |
rsgaley24@gmail.com |
Self |
Ottumwa |
IA |
United States |
Stacey Galey |
Kinnick Galey |
Signed |
1193 |
2022-07-08 10:18 |
Anonymous (not verified) |
173.18.22.217 |
OWWT |
Limited Liability Company |
1915 SE Clovere Ridge Dr. Ankeny IA 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-08 |
Robert M Jackson |
dgfl08051982@gmail.com |
Ankeny |
Polk |
IA |
Lesa Reeves |
Erick Schuldt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert M Jackson |
dgfl08051982@gmail.com |
Owner |
Ankeny |
Polk |
Iowa |
Lesa Reeves |
Erick Sculdt |
Signed |
2082 |
2024-03-08 10:47 |
Anonymous (not verified) |
94.188.205.176 |
T & S Sandblastin and Painting LLC |
Limited Liability Company |
101 Clinton ST Corwith IA 50430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Robert Schissel |
matt.tindall83@gmail.com |
Corwith |
Hancock |
Iowa |
Wendy S Jensen |
Jason Bradley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Schissel |
matt.tindall83@gmail.com |
self |
Corwith |
Hancock |
Iowa |
Wendy S Jensen |
Jason Bradley |
Signed |
489 |
2021-04-20 13:47 |
Anonymous (not verified) |
69.63.16.2 |
Mow-n-Mor Lawn & Landscaping LLC |
Limited Liability Company |
2585 500th St 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. |
2021-04-19 |
Robert Sieren |
mtesdell@yahoo.com |
Kalona |
Johnson |
Iowa |
Scott Freeman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Sieren |
mtesdell@yahoo.com |
Managing Member |
Kalona |
Johnson |
Iowa |
Scott Freeman |
Dyan Kriener |
Signed |
1433 |
2023-01-27 13:24 |
Anonymous (not verified) |
184.97.152.214 |
Rwdcarpet |
Proprietorship |
4927 cedarbrook 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. |
2023-01-27 |
Robert Wayne Durand iii |
rwdcarpet24@gmail.com |
Council bluffs |
Pottawattamie |
Iowa |
Kitty whissinand |
Kelley durand |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Wayne Durand iii |
rwdcarpet24@gmail.com |
Self |
Council bluffs |
Pottawattamie |
Iowa |
Kitty whissinand |
Kelley Durand |
Signed |
575 |
2021-07-14 14:01 |
Anonymous (not verified) |
69.57.205.10 |
Robert W. Cantrell |
Proprietorship |
845 East Redwood Circle, Hanford, CA 93230 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-10 |
Robert Wescott Cantrell |
rcr4@comcast.net |
Hanford |
Kings |
CA |
Shirley J. Loney |
Joel L. Meyer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Westcott Cantrell |
rcr4@comcast.net |
proprietor |
Hanford |
Kings |
CA |
Shirley J. Loney |
Joel L. Meyer |
Signed |
1224 |
2022-07-23 14:14 |
Anonymous (not verified) |
69.57.205.10 |
Robert W. Cantrell |
Proprietorship |
845 East Redwood Circle, Hanford, CA 93230 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Robert Wescott Cantrell |
marquisaviationinc@yahoo.com |
Hanford |
Kings |
CA |
Shirley J. Loney |
Joel L. Meyer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Westcott Cantrell |
marquisaviationinc@yahoo.com |
proprietor |
Hanford |
Kings |
CA |
Shirley J. Loney |
Joel L. Meyer |
Signed |
2118 |
2024-03-27 13:25 |
Anonymous (not verified) |
94.188.207.223 |
Zaragoza Home Solutions LLC |
Limited Liability Company |
1644 E Walnut 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. |
2024-03-27 |
Roberto C. Curiel |
zaragozahomesolutionsllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Francisco A Palomares Zepeda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roberto C Curiel |
zaragozahomesolutionsllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Francisco A Palomares Zepeda |
Signed |
988 |
2022-03-21 10:40 |
Anonymous (not verified) |
173.27.156.183 |
JABS Construction/Finish |
Limited Liability Company |
543 10th 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. |
2022-03-20 |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Clinton |
IA |
United States |
N/A |
N/a |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Owner |
Clinton |
IA |
United States |
N/A |
N/A |
Signed |
989 |
2022-03-21 10:40 |
Anonymous (not verified) |
173.27.156.183 |
JABS Construction/Finish |
Limited Liability Company |
543 10th 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. |
2022-03-20 |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Clinton |
IA |
United States |
N/A |
N/a |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Owner |
Clinton |
IA |
United States |
N/A |
N/A |
Signed |
1038 |
2022-04-11 09:43 |
Anonymous (not verified) |
173.27.156.183 |
JABS Construction/Finish |
Limited Liability Company |
543 10th 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. |
2022-04-11 |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Clinton |
IA |
United States |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay County |
Missouri |
Roberto J Henrickson |
Cody Dunbar |
Signed |
1409 |
2023-01-05 11:55 |
Anonymous (not verified) |
173.23.88.7 |
Top tier gutter systems llc |
Limited Liability Company |
405a 1st Ave sw Cedar Rapids, ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-05 |
Rocky layne smith |
toptierguttersystems@yahoo.com |
Cedar Rapids |
Linn |
IA |
Faye momodu |
Rocky smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rocky smith |
toptierguttersystems@yahoo.com |
Self |
Cedar Rapids |
Linn |
IA |
Faye momodu |
Derrick |
Signed |
501 |
2021-04-29 15:47 |
Anonymous (not verified) |
184.179.6.93 |
Rodney Bohannon |
Proprietorship |
5221 Crogans Way Rd, 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. |
2021-04-29 |
Rodney Bohannon |
bohannonrod@gmail.com |
Council Bluffs |
POTTAWATTAMIE |
iowa |
KIMBERLY L ARFMAN |
Tami Cull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodney Bohannon |
bohannonrod@gmail.com |
Owner |
Council Bluffs |
POTTAWATTAMIE |
IA |
KIMBERLY L ARFMAN |
Tami Cull |
Signed |
1061 |
2022-04-19 19:30 |
Anonymous (not verified) |
172.58.83.52 |
Rodolfo Perez |
Proprietorship |
3420 E 12th 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. |
2022-04-19 |
Rodolfo Perez |
Elgordo0738@gmail.com |
Des Moines |
Polk |
Iowa |
Henry santos |
Larry ramos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Lantz |
Info@lantzelite.com |
Self employed no workers |
Urbandale |
Polk |
Iowa |
Henry santos |
Larry ramos |
Signed |
403 |
2021-02-16 11:20 |
Anonymous (not verified) |
192.30.185.142 |
Rodrigo Ochoa |
Proprietorship |
3310 5th St, 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. |
2021-02-16 |
Rodrigo Ochoa |
jesusochoa1976@icloud.com |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Jenni Ebner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodrigo Ochoa |
jesusochoa1976@icloud.com |
Owner |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Jenni Ebner |
Signed |
2129 |
2024-04-01 14:16 |
Anonymous (not verified) |
94.188.207.227 |
Des Moines Construction LLC |
Limited Liability Company |
6615 SE 3rd St Des Moines IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-01 |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rodrigo Valdes |
desmoinesconstructionllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
877 |
2022-01-31 11:43 |
Anonymous (not verified) |
75.162.226.236 |
Rogelio De La rosa |
Proprietorship |
2104 E 25th 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. |
2022-01-31 |
Rogelio De La rosa jr |
chucotx@rocketmail.com |
Des Moines |
polk |
Ia |
Noreen Henry |
Christian Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rogelio De La Rosa |
chucotx@rocketmail.com |
owner |
Des moines |
polk |
Ia |
Noreen Henry |
Christian Lopez |
Signed |
876 |
2022-01-31 11:31 |
Anonymous (not verified) |
75.162.226.236 |
Leaf Fitters |
Limited Liability Company |
16180 SE Laurel St Des Moines 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-31 |
Rogelio De La Rosa Jr. |
chucotx@rocketmail.com |
Des Moines |
Polk |
Iowa |
Noreen Henry |
Christian Lopez |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Rogelio De La Rosa |
chucotx@rocketmail.com |
self |
Des Moines |
polk |
ia |
noreen henry |
Christian Lopez |
Signed |
611 |
2021-08-19 15:23 |
Anonymous (not verified) |
97.125.53.119 |
Rogelio Lopez Casillas |
Proprietorship |
1175 Office Park Road Apt 109 WDM, 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. |
2021-08-21 |
Rogelio Lopez Casillas |
deb@piciowa.com |
West Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly K Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rogelio Lopez Casillas |
deb@piciowa.com |
subcontractor |
West Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly K Denger |
Signed |
1022 |
2022-03-30 15:08 |
Anonymous (not verified) |
216.51.227.123 |
Elite Business Cleaning |
Limited Liability Company |
1350 Kennel Ct Unit C2 north liberty IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-30 |
rogelio morales ortega |
info@elitebusinesscleaning.com |
iowa city |
johnson |
Iowa |
alma rosa ortega |
john Spencer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elite Business Cleaning |
info@elitebusinesscleaning.com |
Ownerr |
iowa city |
johnson |
iowa |
Alma Rosa Ortega |
John Spender |
Signed |
1307 |
2022-09-14 13:40 |
Anonymous (not verified) |
216.51.227.123 |
elite business ckeaning |
Proprietorship |
1350 kennel ct unit c2 north liberty IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-14 |
rogelio morales ortega |
info@elitebusinesscleaning.com |
iowa city |
johnson |
iowa |
cesar morales ortega |
alma rosa perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
elite busibess cleaning |
info@elitebusinesscleaning.com |
president |
north liberty |
johnson |
iowa |
karina aguilar |
jessica lee |
Signed |
285 |
2020-10-21 16:24 |
Anonymous (not verified) |
66.188.136.150 |
Roger Cole |
Proprietorship |
30 Devon Dr. 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. |
2020-10-21 |
Roger cole |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger Cole |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
898 |
2022-02-04 21:46 |
Anonymous (not verified) |
107.77.161.27 |
Roger De La Rosa |
Proprietorship |
2104 E 25th 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. |
2022-02-04 |
Roger De La Rosa |
roger_dlr72@yahoo.com |
Des Moines |
Polk |
IA |
Noreen Henry |
Christian Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger De La Rosa |
roger_dlr72@yahoo.com |
Owner |
Des Moines |
Polk |
IA |
Noreen Henry |
Christian Lopez |
Signed |
1373 |
2022-11-16 12:28 |
Anonymous (not verified) |
173.22.187.22 |
MCDONALD'S LAWN & TREE SERVICES |
Proprietorship |
1130 N. 4 AVE. W. 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. |
2022-11-16 |
Roger McDonald |
RABBITMCDONALD@HOTMAIL.COM |
Newton |
IA |
United States |
Patricia McMahon |
Bryan McMahon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger McDonald |
RABBITMCDONALD@HOTMAIL.COM |
Self |
Newton |
IA |
United States |
Patricia McMahon |
Bryan McMahon |
Signed |
1611 |
2023-04-27 09:21 |
Anonymous (not verified) |
94.188.205.168 |
powell express moving |
Proprietorship |
2600 Marquette Pl 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. |
2023-04-27 |
Roger Powell |
powellexpressmoving@gmail.com |
Dubuque |
Dubuque |
Iowa |
Connie Powell |
Jay Weiser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger Powell |
powellexpressmoving@gmail.com |
Self |
Dubuque |
Dubuque |
Iowa |
Connie Powell |
Jay Weiser |
Signed |
743 |
2021-11-11 15:19 |
Anonymous (not verified) |
72.13.16.172 |
ROLING TRANSPORT LLC |
Limited Liability Company |
33041 395TH 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 |
ROLING TRUCKING LLC |
dave@allseasonstrucking.com |
BELLEVUE |
JACKSON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ROLING TRUCKING LLC |
dave@allseasonstrucking.com |
PRESIDENT |
BELLEVUE |
JACKSON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
1118 |
2022-05-18 11:12 |
Anonymous (not verified) |
174.215.249.55 |
Nilson construction |
Proprietorship |
3219 bowdoin 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. |
2022-05-18 |
Romel Edenilson saravia Aparicio |
romelsaravia5@gmail.com |
Des Moines |
Polk |
Iowa |
Alvaro camacho |
Ricardo Iyan campuzano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Romel edenilson saravia aparicio |
romelsaravia5@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Alvaro camacho |
Ricardo iyan campuzano |
Signed |
1882 |
2023-10-27 10:40 |
Anonymous (not verified) |
94.188.205.166 |
Ron's SIding and Construction |
Proprietorship |
6097 26th 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. |
2025-02-02 |
Ron Heggebo |
heggebojessica@yahoo.com |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronnie Heggebo |
heggebojessica@yahoo.com |
self |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
1883 |
2023-10-27 10:49 |
Anonymous (not verified) |
94.188.207.228 |
Ron's SIding and Construction |
Proprietorship |
6097 26th 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. |
2023-10-27 |
Ron Heggebo |
heggebojessica@yahoo.com |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Heggebo |
heggebojessica@yahoo.com |
Self |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
276 |
2020-10-08 12:55 |
Anonymous (not verified) |
65.103.82.36 |
Ron Ray |
Limited Liability Company |
311 N Division Creston Iowa 50801 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-08 |
Ron L Ray |
641-782-0521@gmail.com |
Creston |
Union |
Iowa |
Kayla Artioli |
Eric Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron L Ray |
641-782-0521@gmail.com |
Self |
Creston |
Union |
Iowa |
Kayla Artioli |
Eric Johnson |
Signed |
1781 |
2023-08-03 21:23 |
Anonymous (not verified) |
94.188.205.166 |
Ron Peiffer Machine |
Limited Liability Company |
139 S 1st St Harpers Ferry, Ia 52146 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Ron Peiffer |
ron@rpeiffer.com |
Harpers Ferry |
Allamakee |
Iowa |
Marie Burington |
Cassie Bakke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Peiffer |
ron@rpeiffer.com |
myself- SOLE PROPRIETOR |
Harpers Ferry |
Allamakee |
Iowa |
Marie Burington |
Cassie Bakke |
Signed |
683 |
2021-10-20 09:39 |
Anonymous (not verified) |
173.23.253.122 |
Superior Floors |
Limited Liability Company |
704 41st 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 |
Ron Shannon |
ronshannon3831@gmail.com |
West Des Moines |
IA |
United States |
Virginia Shannon |
Virginia Shannon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Shannon |
ronshannon3831@gmail.com |
Self |
West Des Moines |
IA |
United States |
Virginia Shannon |
Virginia Shannon |
Signed |
521 |
2021-05-17 14:23 |
Anonymous (not verified) |
66.188.136.150 |
Ron Wagner |
Proprietorship |
602 1/2 Ave G Apt. 5 Ft. 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. |
2021-05-17 |
Ron Wagner |
kschumacher@tricorinsurance.com |
Ft. Madison |
Lee |
IA |
Jordan Bass |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Wagner |
kschumacher@tricorinsurance.com |
Same |
Ft. Madison |
Lee |
IA |
Jordan Bass |
Shuree Behr |
Signed |
2174 |
2024-04-24 08:22 |
Anonymous (not verified) |
94.188.205.175 |
White's Floorcovering |
Proprietorship |
129 Hillcrest Dr. Biggsville, IL 61418 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Ron White |
hntwhite@frontiernet.net |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron White |
hntwhite@frontiernet.net |
owner |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
1153 |
2022-06-13 16:22 |
Anonymous (not verified) |
216.9.166.5 |
Ronald B Blakley |
Proprietorship |
2001 St Bridgets Rd NE, 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. |
2022-06-08 |
Ronald B Blakley |
sanjahunt@gmail.com |
Solon |
Johnson |
Iowa |
Scott G Freeman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald B Blakley |
Sanjahunt@gmail.com |
Owner |
Solon |
Johnson |
Iowa |
Scott G Freeman |
Dyan Kriener |
Signed |
332 |
2020-12-04 10:57 |
Anonymous (not verified) |
66.188.136.150 |
Ron's Trucking LLC |
Limited Liability Company |
16007 Oak Avenue, Oak Forrest, IL 60452 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-04 |
Ronald Clark Jr. |
kschumacher@tricorinsurance.com |
Oak Forrest |
Cook |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron's Trucking LLC |
kschumacher@tricorinsurance.com |
Same |
Oak Forrest |
Cook |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
1151 |
2022-06-13 09:29 |
Anonymous (not verified) |
208.126.52.58 |
Ronald D. Heneke |
Proprietorship |
PO Box 114 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-13 |
Ronald D. Heneke |
rheneke@email.com |
Delmar |
Clinton |
Iowa |
Mary S. O’Dell |
Neal J. Damm |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald D. Heneke |
rheneke@email.com |
Self |
Delmar |
Clinton |
Iowa |
Mary S. O’Dell |
Neal J. Damm |
Signed |
943 |
2022-03-03 13:49 |
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 |
Ronald Jarrett |
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 |
Member of LLC |
Newhall |
Benton |
Iowa |
Ashlyn Christianson |
Angie McFarland |
Signed |
1630 |
2023-05-09 08:54 |
Anonymous (not verified) |
94.188.207.225 |
Ronald McChane |
Proprietorship |
400 Lewellen dr nw, CEDAR RAPIDS, IA 52405, 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. |
2023-05-09 |
Ronald McChane |
rws79213@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Jordan Nisiewicz |
Charles Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Iowa |
Charles Woods |
Jordan Loyd |
Signed |
837 |
2022-01-13 08:38 |
Anonymous (not verified) |
169.197.65.8 |
Reyes Concrete Services llc |
Limited Liability Company |
101 Perry St South Jesup, 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. |
2022-01-13 |
Ronald Reyes |
ronlreyes1975@gmail.com |
Jesup |
Buchanan |
Iowa |
Jacolin Reyes |
Ronald Reyes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald Reyes |
ronlreyes1975@gmail.com |
Same |
Jesup |
Buchanan |
Iowa |
Jacolin Reyes |
Ronald Reyes |
Signed |
427 |
2021-03-10 11:52 |
Anonymous (not verified) |
66.188.136.150 |
Ronald Tessen |
Proprietorship |
493 Hill St. Green Lake, WI 54941 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Ronald Tessen |
kschumacher@tricorinsurance.com |
Green Lake |
Green Lake |
WI |
Russell Masartis |
Amanda Seeberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald Tessen |
kschumacher@tricorinsurance.com |
Same |
Green Lake |
Green Lake |
WI |
Russell Masartis |
Amanda Seeberger |
Signed |
1688 |
2023-06-13 09:29 |
Anonymous (not verified) |
94.188.207.228 |
Ron Burbach |
Proprietorship |
7760 commerce park Dubuque Iowa 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Ronald V Burbach |
allgreenron@msn.com |
Dubuque |
Dubuqie |
Iowa |
Mia Burnach |
Jerry david |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald V Burbach |
allgreenron@man.com |
Same |
Dubuque |
Dubuque |
Iowa |
Mia F Burbach |
Jerry David |
Signed |
1925 |
2023-11-28 09:44 |
Anonymous (not verified) |
94.188.207.224 |
Pietro Solutions |
Limited Liability Company |
719 11th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-28 |
Ronaldo Di Pietro |
girodp@gmail.com |
Rock Island |
Rock Island |
IL |
Rita de Cássia Gallo |
Antonio Carlos Gallo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronaldo Di Pietro |
girodp@gmail.com |
Self |
Rock Island |
Rock Island |
IL |
Rita de Cássia Gallo |
Antonio Carlos Gallo |
Signed |
1407 |
2023-01-04 13:26 |
Anonymous (not verified) |
67.55.135.18 |
Duncan Customs LLC |
Limited Liability Company |
8857 Union Cir. 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. |
2023-01-04 |
Rory Eugene Duncan |
ddmusicsolutions@gmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Travis Duncan |
Alethea Duncan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rory Duncan |
ddmusicsolutions@gmail.com |
self |
Cedar Falls |
Black Hawk |
Iowa |
Travis Duncan |
Alethea Duncan |
Signed |
1968 |
2023-12-28 14:57 |
Anonymous (not verified) |
94.188.205.175 |
Rose Frimpong |
Proprietorship |
2110 NW 31st St. Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-28 |
Rose Frimprong |
domena69@hotmail.com |
Ankeny |
Polk |
Iowa |
Amabilis Ngwa |
Chris Abonge |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rose Frimpong |
domena69@hotmail.com |
Self-employed |
Ankeny |
Polk |
Iowa |
Chris Abonge |
Amabilis Ngwa |
Signed |
423 |
2021-03-05 13:55 |
Anonymous (not verified) |
71.39.227.238 |
RoseMary Phillips |
Proprietorship |
1107 Walnut 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. |
2021-03-05 |
RoseMary Phillips |
stevep@phillipsassociatesins.net |
Linden |
Guthrie |
Iowa |
Steven Phillips |
Abbey Luellen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RoseMary Phillips |
stevep@phillipsassociatesins.net |
Self |
Linden |
Guthrie |
Iowa |
Steve Phillips |
Abbey Luellen |
Signed |
1659 |
2023-05-23 13:39 |
Anonymous (not verified) |
94.188.205.168 |
Rosendo Mora |
Proprietorship |
222 E Webster Street, Goldfield IA 50542 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Rosendo Mora |
office.seamlesspros@icloud.com |
Goldfield |
Wright |
Iowa |
Anthony Buck |
Troy Knutson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rosendo Mora |
office.seamlesspros@icloud.com |
Self |
Goldfield |
Wright |
Iowa |
Anthony Buck |
Troy Knutson |
Signed |
1440 |
2023-02-06 14:24 |
Anonymous (not verified) |
69.40.94.166 |
ESW CONSTRUCTION INC |
Partnership |
315 hIGHWAY 22, KESWICK IA 50136 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
ROSS SIEREN |
rtsieren@gmail.com |
KESWICK |
KEOKUK |
IOWA |
JULIE WHITE |
REBECCA APPLEGET |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BARBARA EDMUNDSON |
barb@iowacropservice.com |
agent |
SIGOURNEY |
KEOKUK |
IOWA |
JULIE WHITE |
REBECCA APPLEGET |
Signed |
1041 |
2022-04-12 09:39 |
Anonymous (not verified) |
173.31.148.43 |
PAPA'S SMOKIN MEAT |
Proprietorship |
1940 147TH ST 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. |
2022-04-12 |
ROXANNE MORISTON |
MORISTON2@YAHOO.COM |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ROXANNE MORISTON |
MORISTON2@YAHOO.COM |
SELF |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
865 |
2022-01-27 12:53 |
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 |
Roy Chamra |
apchamra@gmail.com |
Rose Hill |
Iowa |
United States |
Steven 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 |
Roy Chamra |
Connie Van Klootwyk |
Signed |
891 |
2022-02-03 15:25 |
Anonymous (not verified) |
173.23.180.117 |
Roy Dawson |
Proprietorship |
2602 Green Creek, 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. |
2022-02-03 |
Roy Dawson |
roydawson19@gmail.com |
Cedar Falls |
Black Hawk County |
Iowa |
Nickole Pry |
Christine Willis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roy Dawson |
roydawson19@gmail.com |
Same person |
Cedar Falls |
Black Hawk |
Iowa |
Nickole Pry |
Christine Willis |
Signed |
1138 |
2022-06-01 15:01 |
Anonymous (not verified) |
173.18.233.175 |
Roy Rohwedder |
Proprietorship |
296 24th 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. |
2022-06-01 |
Roy h Rohwedder |
rohwedder.roy@yahoo.com |
Cedar Rapids |
linn |
iowa |
Cash Rohwedder |
Brian Ashlock |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
Genaral Manager |
Cedar Rapids |
Linn |
IOWA |
Branden Peters |
Jenny Vaske |
Signed |
1842 |
2023-09-14 14:08 |
Anonymous (not verified) |
94.188.205.174 |
RM Construction |
Limited Liability Company |
1623 120th Street, Hazleton, 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. |
2022-09-14 |
Roy Miller |
roymiller@aol.com |
Hazleton |
Buchanan |
Iowa |
Steve Frost |
Julie Schick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roy Miller |
roymiller@aol.com |
self |
Hazleton |
Buchanan |
Iowa |
Steve Frost |
Julie Schick |
Signed |
1983 |
2024-01-11 13:02 |
Anonymous (not verified) |
94.188.205.168 |
r&k propety solutions |
Proprietorship |
po box 53 cedar rapids iowa 52406 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
roy rohwedder |
rohwedder.roy@yahoo.com |
Cedar Rapids |
linn |
ia |
Brian Ashlock |
tim vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Center Point |
Benton |
ia |
Tim Vaske |
Roy Rohwedder |
Signed |
220 |
2020-08-02 13:45 |
Anonymous (not verified) |
99.203.112.113 |
R&G SEAMLESS GUTTERS |
Proprietorship |
3244 Dubuque Ave, 3244 Dubuque Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-02 |
Ruben Munoz Haro |
munozharoruben@gmail.com |
Des Moines |
Polk |
Estados Unidos |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ruben Munoz- R&G SEAMLESS GUTTERS |
Munozharoruben@gmail.com |
owner |
3244 Dubuque Ave Des Moines Iowa 50317 |
polk |
iowa |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
522 |
2021-05-17 20:27 |
Anonymous (not verified) |
50.81.4.25 |
Crew Cut Lawn Care |
Limited Liability Company |
7820 1st 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. |
2021-05-17 |
Rupert McKendly Ellis |
wideglide94@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Adrian Pink |
Lorraine Ellis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rupert M Ellis |
wideglide94@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Adrian Pink |
Lorraine |
Signed |
528 |
2021-05-21 14:06 |
Anonymous (not verified) |
66.188.136.150 |
Russell Masartis |
Proprietorship |
481 Clarendon East Dubuque, IL 61025 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-21 |
Russell Masartis |
kschumacher@tricorinsurance.com |
East Dubuque |
Jo Daviess |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Russell Masartis |
kschumacher@tricorinsurance.com |
Same |
East Dubuque |
Jo Daviess |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
1888 |
2023-10-31 15:59 |
Anonymous (not verified) |
94.188.207.225 |
CEM Businesses LLC |
Limited Liability Company |
608 Evergreen Cir 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. |
2023-10-31 |
Ryan Canales |
ryancanales44@gmail.com |
West 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 |
2051 |
2024-02-16 17:40 |
Anonymous (not verified) |
94.188.205.174 |
Ryans Outdoor Services LLC |
Limited Liability Company |
2731 Pinard 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. |
2024-02-16 |
Ryan Carroll |
ryancarrolls1226@icloud.com |
Dubuque |
Dubuque |
Iowa |
Rob McDonald |
Philip Grommet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Carroll |
ryancarrolls1226@icloud.com |
Self |
Dubuque |
Dubuque |
Iowa |
Rob McDonald |
Philip Grommet |
Signed |
1624 |
2023-05-03 10:30 |
Anonymous (not verified) |
94.188.207.227 |
Ryan Deymonaz |
Proprietorship |
2303 Kingsway 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. |
2023-05-03 |
Ryan Deymonaz |
ryan.deymonaz@gmail.com |
Bettendorf |
Iowa |
United States |
Ryan Deymonaz |
Hannah Baker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Deymonaz |
ryan.deymonaz@gmail.com |
Self |
Bettendorf |
Iowa |
United States |
Ryan Deymonaz |
Hannah Baker |
Signed |
732 |
2021-11-09 15:25 |
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 |
Ryan Drabek |
ryand@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Dustin Kohler |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
toryw@unitedtradesgroup.org |
Owner, Management |
Norwalk |
Warren |
Iowa |
Trevor Spidle |
Dustin Kohler |
Signed |
1004 |
2022-03-23 15:01 |
Anonymous (not verified) |
104.201.110.2 |
Ryan Fischer |
Proprietorship |
809 8th St 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. |
2022-03-23 |
Ryan Fischer |
rfischer@phillipsstaffod.com |
Des Moines |
Polk |
IA |
Josh Stafford |
Desiree Dennis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Fischer |
rfischer@phillipsstafford.com |
Self |
DES MOINES |
IA |
United States |
Josh Stafford |
Desiree Dennis |
Signed |
1953 |
2023-12-12 15:38 |
Anonymous (not verified) |
94.188.207.226 |
Ryan Gideon |
Proprietorship |
9320 Elmcrest 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. |
2023-12-12 |
Ryan Gideon |
rgid8403@gmail.com |
Norwalk |
Warren |
IA |
Jim Lane |
Jim Lane |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Gideon |
rgid8403@gmail.com |
Owner |
Norwalk |
Warren |
IA |
jim Lane |
Jim Lane |
Signed |
1064 |
2022-04-21 12:48 |
Anonymous (not verified) |
174.199.77.87 |
Hocken Construction LLC |
Limited Liability Company |
926 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. |
2021-01-01 |
Ryan Hocken |
ryan.hocken@yahoo.com |
Osage |
Mitchell |
Iowa |
Melissa Hocken |
Tyler Schwarck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Hocken |
ryan.hocken@yahoo.com |
Owner |
Osage |
Mitchell |
Iowa |
Melissa Hocken |
Tyler Schwarck |
Signed |
1447 |
2023-02-09 16:12 |
Anonymous (not verified) |
94.188.205.166 |
Ryan Klocke |
Limited Liability Company |
315 1st Street Templeton, IA 54163 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-09 |
Ryan Klocke |
heidi@nextgenagsupply.com |
Templeton |
Carroll |
Iowa |
Kim Gienau |
Zach Counsell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Klocke |
heidi@nexgenagsupply.com |
President |
Templeton |
Carroll |
Iowa |
Kim Gienau |
Zach Counsell |
Signed |
8 |
2019-12-13 12:18 |
Anonymous (not verified) |
173.18.3.76 |
Knight Electric, LLC |
Limited Liability Company |
200 E Aurora Ave, Des Moines, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-13 |
Ryan Lewis |
ryan@knightelectric.biz |
Des Moines |
Polk |
Iowa |
Angie Kinsey |
Jon Stetzel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Lewis |
ryan@knightelectric.biz |
Member/Owner |
Des Moines |
Polk |
Iowa |
Angie Kinsey |
Jon Stetzel |
Signed |
199 |
2020-07-09 10:49 |
Anonymous (not verified) |
167.142.98.40 |
Ryan Stott |
Proprietorship |
1513 Hawthorne 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. |
2020-07-09 |
Ryan Lynn Stott |
rlstott@hotmail.com |
Jefferson |
Greene |
Iowa |
Brock Chisum |
Brian Chisum |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Stott |
rlstott@hotmail.com |
self |
Jefferson |
Greene |
Iowa |
Brock Chisum |
Brian Chisum |
Signed |
2215 |
2024-05-08 22:07 |
Anonymous (not verified) |
94.188.207.223 |
Self Employed-Ryan Thornton |
Proprietorship |
8403 Horton Ave 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. |
2024-05-08 |
Ryan M Thornton |
rt6366155@gmail.com |
Urbandale |
Polk |
Iowa |
April Oxendale |
Bruce Thornton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Thornton |
rt6366155@gmail.com |
Self |
Urbandale |
Polk |
Iowa |
April Oxendale |
Bruce Thornton |
Signed |
1589 |
2023-04-20 12:57 |
Anonymous (not verified) |
94.188.205.167 |
Grace Flooring |
Proprietorship |
2001 W 2nd Street perry, Iowa 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. |
2023-04-20 |
Ryan Michael Tool |
GraceFlooring0@gmail.com |
Perry |
Dallas |
IA |
Jennifer Lynn Tool |
Shane Workman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grace Flooring |
GraceFlooring0@gmail.com |
Owner |
Perry |
Dallas |
IA |
Jennifer Tool |
Shane workman |
Signed |
407 |
2021-02-18 10:47 |
Anonymous (not verified) |
165.225.61.119 |
Ryan Myers Painting |
Proprietorship |
836 25th 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 |
Ryan Myers |
tickspoon@yahoo.com |
Rock Island |
Rock Island |
IL |
Seth Rowland |
Jay Romeo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Myers |
tickspoon@yahoo.com |
Self |
Rock Island |
Rock Island |
IL |
Seth Rowland |
Jay Romeo |
Signed |
1135 |
2022-05-31 12:06 |
Anonymous (not verified) |
174.215.227.133 |
Plagman Transportation |
Limited Liability Company |
1306 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. |
2022-05-31 |
Ryan Plagman |
rplagman@gmail.com |
Adel |
Dallas |
Ia |
Chris Christensen |
Jack Ruby |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Plagman |
rplagman@gmail.com |
Same |
Adel |
Dallas |
Ia |
Chris Christensen |
Jack Ruby |
Signed |
425 |
2021-03-05 16:03 |
Anonymous (not verified) |
65.103.82.36 |
Ryan Richard |
Proprietorship |
1425 W 34th Street, 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. |
2020-06-15 |
Ryan Richard |
RRichard@gmail.com |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Richard |
RRichard@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
187 |
2020-06-15 11:55 |
Anonymous (not verified) |
67.60.42.173 |
SANDS CONSTRUCTION LLC |
Limited Liability Company |
3812 Sioux River 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-06-15 |
Ryan Sands |
rn_sands@hotmail.com |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ryan Sands |
rn_sands@hotmail.com |
self/ Owner/ Operator |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
188 |
2020-06-15 11:55 |
Anonymous (not verified) |
67.60.42.173 |
SANDS CONSTRUCTION LLC |
Limited Liability Company |
3812 Sioux River 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-06-15 |
Ryan Sands |
rn_sands@hotmail.com |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ryan Sands |
rn_sands@hotmail.com |
self/ Owner/ Operator |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
1875 |
2023-10-23 11:34 |
Anonymous (not verified) |
94.188.205.176 |
Makers Blinds LLC |
Limited Liability Company |
3220 44Th 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. |
2023-10-23 |
Ryan Seiler |
makersblinds@gmail.com |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Seiler |
makersblinds@gmail.com |
Manager |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
468 |
2021-04-12 14:54 |
Anonymous (not verified) |
173.27.224.230 |
PCI Turf LLC |
Limited Liability Company |
1313 N Grant St. 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. |
2021-04-12 |
Ryan Trout |
rtrout22@yahoo.com |
Knoxville |
Marion |
Iowa |
Joseph Durham |
Carson Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Trout |
pci.turf@yahoo.com |
Self- owner/operator |
Knoxville |
Marion |
Iowa |
Joseph Durham |
Carson Peterson |
Signed |
1834 |
2023-09-08 15:04 |
Anonymous (not verified) |
94.188.205.177 |
Ryan Tucker |
Proprietorship |
19000 hwy 69 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-08 |
Ryan Tucker |
rtlltucker@yahoo.com |
Indianola |
Warren |
Iowa |
Brooke Prior |
Aly Brose |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Tucker |
rtlltucker@yahoo.com |
Officer |
Indianola |
Warren |
Iowa |
Brooke Prior |
Aly Brose |
Signed |
1811 |
2023-08-21 17:03 |
Anonymous (not verified) |
94.188.205.167 |
Cardinal Concrete LLC |
Limited Liability Company |
503 17th 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. |
2023-08-21 |
Ryan Woods |
cardinalconcrete.cw@gmail.com |
Boone |
Boone |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Woods |
cardinalconcrete.cw@gmail.com |
100% owner |
Boone |
Boone |
Iowa |
Jon Buller |
Terry Miles |
Signed |
1499 |
2023-03-07 11:21 |
Anonymous (not verified) |
94.188.205.177 |
Ryan Zimmerman |
Proprietorship |
17606 35th St Lime Springs, 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. |
2022-04-27 |
Ryan Zimmerman |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
47 |
2020-01-28 16:35 |
Anonymous (not verified) |
173.18.3.76 |
Delic Marble and Tile LLC |
Limited Liability Company |
24 Ellefson Dr PO Box 413 DeSoto, IA 50069 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-27 |
Sabahudin Delic |
delicgraniteandtile@gmail.com |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adin Delic |
delicgraniteandtile@gmail.com |
LLC Member |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
1566 |
2023-04-12 08:40 |
Anonymous (not verified) |
94.188.205.169 |
Sabokwigura Jonathan |
Proprietorship |
1613 12th Avenue Southeast, Cedar Rapids, IA 52401, 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. |
2023-04-12 |
Sabokwigura Jonathan |
nzobojo@gmail.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 |
1853 |
2023-09-26 10:16 |
Anonymous (not verified) |
94.188.205.177 |
Saketh Mahavadi |
Limited Liability Company |
294 s 83rd 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. |
2023-09-26 |
Saisaketh |
sakethmahavadi@gmail.com |
West Des Moines |
IA |
United States |
David Chan |
Ahnaf Yeasin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Chan |
Davidchan8873@gmail.com |
Business Partner |
West Des Moines |
IA |
United States |
Saketh Mahavadi |
Ahnaf Yeasin |
Signed |
1369 |
2022-11-11 13:02 |
Anonymous (not verified) |
173.29.231.17 |
Salvador Cardenas |
Limited Liability Company |
5206 SE 31st Street, 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. |
2022-11-11 |
Salvador Cardenas |
salvadorcardenas16@icloud.com |
Des Moines |
Polk |
Iowa |
Omar Gonzalez |
Omar Gonzalez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Salvador Cardenas |
salvadorcardenas16@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Omar Gonzalez |
Omar Gonzalez |
Signed |
694 |
2021-10-26 15:30 |
Anonymous (not verified) |
65.144.174.26 |
Escoto Tile |
Proprietorship |
6820 University Ave 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. |
2021-10-26 |
Salvador Escoto |
escototile@gmail.com |
Windsor Heights |
Polk |
Iowa |
Claudia Veronica Ojeda Escoto |
Josefina Escoto |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Salvador Escoto |
escototile@gmail.com |
Owner |
WINDSOR HEIGHTS |
Polk |
Iowa |
Claudia Veronica Ojeda Escoto |
Josefina Escoto |
Signed |
2189 |
2024-04-29 09:23 |
Anonymous (not verified) |
94.188.207.225 |
Sals Home Improvements LLC |
Limited Liability Company |
3750 NW Maple 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. |
2024-04-29 |
Salvador Gomez |
salvadorg27@hotmail.com |
Ankeny |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Salvador Gomez |
salvadorg27@hotmail.com |
Self |
Ankeny |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
1587 |
2023-04-19 09:12 |
Anonymous (not verified) |
94.188.205.169 |
Sami Jo T Tappe |
Proprietorship |
7044 Carey 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. |
2023-04-19 |
Sami Jo Tappe |
samijotappe@gmail.com |
Johnston |
Polk |
Iowa |
Olga Sanchez |
Matthew Tappe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sami Jo Tappe |
samijotappe@gmail.com |
Self |
Johnston |
Polk |
Iowa |
Olga Sanchez |
Matthew Tappe |
Signed |
111 |
2020-04-06 16:04 |
Anonymous (not verified) |
209.152.124.33 |
SM Tile Design LLC |
Limited Liability Company |
670 Daybreak 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. |
2020-04-06 |
Samir Mulalic |
Smtiledesign@gmail.com |
WAUKEE |
Dallas |
Iowa |
Shawn Stanley |
Saneta Dzankovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samir Mulalic |
Smtiledesign@gmail.com |
Same |
WAUKEE |
Dallas |
Iowa |
Shawn Stanley |
Saneta Dzankovic |
Signed |
1661 |
2023-05-24 10:12 |
Anonymous (not verified) |
94.188.205.167 |
Might Lawn Care |
Limited Liability Company |
1920 W 70th 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. |
2023-05-24 |
Samuel Lawrence Might |
mightlawncare@gmail.com |
Davenport |
Scott |
IA |
Meredith Might |
Suzette Henriksen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samuel Might |
mightlawncare@gmail.com |
Owner |
Davenport |
Scott |
IA |
Meredith Might |
Suzette Henriksen |
Signed |
457 |
2021-04-04 17:35 |
Anonymous (not verified) |
104.237.118.236 |
Lundt Transport, LLC |
Limited Liability Company |
3322 Y 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. |
2021-04-04 |
SAMUEL LUNDT |
samuelrl1998@gmail.com |
FAIRBANK |
Iowa |
Iowa |
CYNTHIA LUNDT |
KATLYN HILL |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAMUEL LUNDT |
samuelrl1998@gmail.com |
SELF |
FAIRBANK |
FAYETTE |
Iowa |
CYNTHIA LUNDT |
KATLYN HILL |
Signed |
1161 |
2022-06-22 19:41 |
Anonymous (not verified) |
208.38.229.190 |
Samuel Perez |
Proprietorship |
6523 N Main Street 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. |
2022-06-22 |
Samuel Perez |
samuelperez@live.com |
Davenport |
Scott |
Iowa |
Raven Perez |
Omar Sanchez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samuel Perez |
samuelperez@live.com |
Self |
Davenport |
Scott |
Iowa |
Raven Perez |
Omar Sanchez |
Signed |
1571 |
2023-04-13 10:30 |
Anonymous (not verified) |
94.188.205.177 |
Pierick Enterprise 2 |
Limited Liability Company |
806 6oth 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. |
2023-04-13 |
SAMUEL PIERICK |
wirehairguids@gmail.com |
Pleasantville |
IA |
United States |
Kelly Wyckoff |
Andy Wyckoff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAMUEL PIERICK |
wirehairguids@gmail.com |
Member |
Pleasantville |
IA |
United States |
Kelly Wyckoff |
Andy Wyckoff |
Signed |
578 |
2021-07-16 15:26 |
Anonymous (not verified) |
184.80.177.137 |
Scotty's Appliance & TV, LLC |
Limited Liability Company |
529 5th St NW - 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. |
(1) I am not electing the employers’ liability coverage. |
2021-07-16 |
Sandra Krogman |
jheims@english-insurance.com |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
Iowa |
Joyce Heims |
Derrick Parsons |
Signed |
2124 |
2024-03-28 13:47 |
Anonymous (not verified) |
94.188.207.225 |
Gudiel Construction & Masonry LLC |
Limited Liability Company |
303 Lacona 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. |
2024-03-28 |
Santiago Gudiel Lopez |
gudielsantiago972@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Santiago Gudiel Lpez |
gudielsantiago972@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
690 |
2021-10-26 14:23 |
Anonymous (not verified) |
65.144.174.26 |
Santiago Rojas |
Proprietorship |
1359 22nd 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. |
2021-10-26 |
Santiago Rojas |
rojassr09@gmail.com |
Des Moines |
Polk |
Iowa |
David Rojas |
Beatriz Hernandez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Santiago Rojas |
rojassr09@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
David Rojas |
Beatriz Hernandez |
Signed |
60 |
2020-02-12 10:10 |
Anonymous (not verified) |
198.167.182.164 |
Sara Torres |
Proprietorship |
419 Lilac St, Tiffin, IA 52340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-11 |
Sara Torres |
skb_blue08@hotmail.com |
Tiffin |
Johnson |
Iowa |
Steven J Fishman |
E. Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sara Torres |
skb_blue08@hotmail.com |
Owner |
Tiffin |
Johnson |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
828 |
2022-01-11 10:34 |
Anonymous (not verified) |
74.215.151.63 |
Marr Arnold Planning |
Limited Liability Company |
1328 California Ave. 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. |
2022-01-11 |
Sarah Arnold |
sarahkarnold@gmail.com |
Cincinnati |
Hamilton |
Ohio |
April Humphreys |
Amy Burns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Arnold |
sarah@marrarnoldplanning.com |
Self |
Cincinnati |
Hamilton |
Ohio |
Amy Burns |
April Humphreys |
Signed |
1696 |
2023-06-19 09:11 |
Anonymous (not verified) |
94.188.205.174 |
Spruce Cleaning Co |
Proprietorship |
2302 Cedar Street Granger, Iowa 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. |
2023-06-19 |
Sarah Champion |
Sprucecleaningcodsm@gmail.com |
Granger |
Dallas |
Iowa |
Amy Greek |
Noah Bassett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Champion |
Sprucecleaningcodsm@gmail.com |
Employer |
Granger |
Dallas |
Iowa |
Amy Greek |
Noah Bassett |
Signed |
22 |
2020-01-02 14:52 |
Anonymous (not verified) |
173.17.129.166 |
Dan & Sarah Gudenkauf |
Proprietorship |
3277 180th Ave, Ryan, IA 52330 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-02 |
Sarah Gudenkauf |
dandselectricmotor@gmail.com |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Gudenkauf |
dandselectricmotor@gmail.com |
Owner |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
362 |
2021-01-14 12:15 |
Anonymous (not verified) |
173.26.157.255 |
Shear Bliss Pet Salon |
Limited Liability Company |
824 Ansborough Ave. 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. |
2021-01-14 |
Sarah K Bebee |
shearblisspet@aol.com |
Hudson |
Black Hawk |
Iowa |
Janice Rae Bebee |
Danny J Bebee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Bebee |
shearblisspet@aol.com |
self |
Hudson |
Black Hawk |
Iowa |
Janice Rae Bebee |
Danny J Bebee |
Signed |
345 |
2020-12-29 09:20 |
Anonymous (not verified) |
173.18.16.129 |
Eben-Ezer Concrete Services |
Proprietorship |
1283 dixon 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. |
2020-12-29 |
Saul Artero |
Artro50313@yahoo.com |
Des Moines |
Polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Saul Artero |
Artro50313@yahoo.com |
owner |
des moines |
Polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
179 |
2020-06-09 11:22 |
Anonymous (not verified) |
173.31.147.225 |
SAUL GUERARA MEZA |
Proprietorship |
26 WESTVIEW DRIVE APT 5 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. |
2020-05-21 |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUERARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
ESMIRALDO JIMENEZ |
TAMI KLEIN |
Signed |
342 |
2020-12-28 10:19 |
Anonymous (not verified) |
173.31.147.225 |
SAUL GUEVARA MEZA |
Proprietorship |
26 WESTVIEW DRIVE APARTMENT 5 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. |
2020-12-22 |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNG WIRTH |
Signed |
1941 |
2023-12-06 11:52 |
Anonymous (not verified) |
94.188.205.167 |
GUEVARA CONCRETE LLC |
Limited Liability Company |
26 WESTVIEW DR APT 5 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. |
2023-12-06 |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IA |
TAMI SUE KLEIN |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IA |
TAMI SUE KLEIN |
JENNIFER JANET YOUNGWIRTH |
Signed |
1216 |
2022-07-20 16:24 |
Anonymous (not verified) |
208.38.231.24 |
Leaf Filter |
Limited Liability Partnership |
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 |
Savannah Taets |
savannahtaets@gmail.com |
Davenport |
Scott |
Iowa |
Savannah Taets |
Layman Miller |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jennifer Stricklett |
jennifer.stricklett@suracy.com |
Insurance agent |
Davenport |
Scott |
Iowa |
Savannah Taets |
Layman Miller |
Signed |
1510 |
2023-03-09 10:57 |
Anonymous (not verified) |
94.188.207.226 |
Sawyer Eblen |
Proprietorship |
14411 293rd Ave 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. |
2023-03-09 |
Sawyer Eblen |
sawyer.eblen@gmail.com |
Belgrade |
MN |
United States |
Brandon Keller |
Mitchell Vetsch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sawyer Eblen |
sawyer.eblen@gmail.com |
Owner |
Belgrade |
MN |
United States |
Brandon Keller |
Mitchell Vetsch |
Signed |
745 |
2021-11-11 15:24 |
Anonymous (not verified) |
72.13.16.172 |
SCHLECHT TRUCKING LLC |
Limited Liability Company |
107 SOUTH 1ST 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. |
2019-11-18 |
SCHLECHT TRUCKING LLC |
dave@allseasonstrucking.com |
SPRINGBROOK |
JACKSON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SCHLECHT TRUCKING LLC |
dave@allseasonstrucking.com |
PRESIDENT |
SPRINGBROOK |
JACKSON |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
1169 |
2022-06-23 16:23 |
Anonymous (not verified) |
159.45.71.17 |
Whitlow Remodeling and Home Services, LLC |
Limited Liability Company |
6421 NW 54th Ct Johnston Iowa 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. |
2022-06-23 |
Scot Alan Whitlow |
resaw375@msn.com |
Johnston |
Polk |
Iowa |
Erin Scanlan |
Charles Thorn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scot Alan Whitlow |
resaw375@msn.com |
Owner |
Johnston |
Polk |
Iowa |
Erin Scanlan |
Charles Thorn |
Signed |
1346 |
2022-10-26 11:54 |
Anonymous (not verified) |
172.86.53.114 |
Iowa Reconstruction Services llc |
Limited Liability Company |
2612 E Quarry Rd, 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. |
2022-10-26 |
Scott A Hambly |
Iowareconsvcs@yahoo.com |
Waterloo |
Black hawk |
Iowa |
Roger Turner |
Judy Turner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Hambly |
Iowareconsvcs@yahoo.com |
Self |
Waterloo |
Black hawk |
Iowa |
Roger Turner |
Judy Turner |
Signed |
1832 |
2023-09-08 12:01 |
Anonymous (not verified) |
94.188.207.226 |
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 |
Scott Andrew Griffin |
G6@q.com |
Jewell |
Hamilton |
Iowa |
Colten Abram Griffin |
Hunter Austin Griffin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colten Abram Griffin |
G6@q.com |
Partner |
Ames |
Story |
Iowa |
Hunter Austin Griffin |
Scott Andrew Griffin |
Signed |
698 |
2021-10-28 16:09 |
Anonymous (not verified) |
71.228.88.54 |
Warren Nelson |
Proprietorship |
2525 Nebraska Street, 106, Sioux City, Iowa 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. |
2021-10-28 |
Scott D. Nelson |
scottdnelson@hotmail.com |
Sioux City |
Woodbury |
Iowa |
Wallace E Sheets |
Abby McDermott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beth L Sheets |
w143bs@verizon.net |
Daughter |
Sarasota |
Manatee |
Florida |
Wallace E. Sheets |
Abby McDermott |
Signed |
263 |
2020-09-21 09:49 |
Anonymous (not verified) |
66.188.136.150 |
Scott Kunz |
Proprietorship |
114 10th Ave. Camanche, IA 52730 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Scott Kunz |
kschumacher@tricorinsurance.com |
Camanche |
Clinton |
IA |
Russell Masartis |
Angie Olds |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Kunz |
kschumacher@tricorinsurance.com |
Same |
Camanche |
Clinton |
IA |
Russell Masartis |
Angie Olds |
Signed |
2096 |
2024-03-14 14:53 |
Anonymous (not verified) |
94.188.205.168 |
Scott Allen |
Proprietorship |
2603 Bryant Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-14 |
Scott Michael Allen |
allen.scottm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Daniel Bryant Bliek |
Jennifer Lee Allen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Michael Allen |
allen.scottm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Daniel Bryant Bliek |
Jennifer Lee Allen |
Signed |
1824 |
2023-08-29 16:20 |
Anonymous (not verified) |
94.188.205.176 |
Miller Construction Siding & Windows, LLC |
Limited Liability Company |
3104 S.W. 26TH STREET, 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. |
2023-08-29 |
SCOTT MICHAEL DORAU |
SMD50021@GMAIL.COM |
Ankeny |
Polk |
United States |
Christopher Bohn |
Jeffrey Bohn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SCOTT MICHAEL DORAU |
SMD50021@GMAIL.COM |
PRESIDENT |
Ankeny |
POLK |
United States |
CHRISTOPHER BOHN |
JEFFREY BOHN |
Signed |
2205 |
2024-05-07 08:56 |
Anonymous (not verified) |
94.188.207.227 |
MILLER CONSTRUCTION SIDING & WINDOWS, LLC |
Limited Liability Company |
3104 SW 26TH STREET, 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. |
2024-05-07 |
SCOTT MICHAEL DORAU |
scott@millersidingandwindows.com |
ANKENY |
POLK |
IOWA |
ADAM BOGE |
LANCE WEBSTER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SCOTT MICHAEL DORAU |
scott@millersidingandwindows.com |
OWNER |
ANKENY |
POLK |
IOWA |
ADAM BOGE |
LANCE WEBSTER |
Signed |
543 |
2021-06-16 12:49 |
Anonymous (not verified) |
174.250.64.145 |
McCulloch Construction LLC |
Limited Liability Company |
2590 SE 68TH 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. |
2021-04-01 |
Scott Rouse |
MCCULLOCHCONSTRUCTION78@GMAIL.COM |
PLEASANT HILL |
Polk |
IA |
Joel Rouse |
Shonna Rouse |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Rouse |
MCCULLOCHCONSTRUCTION78@GMAIL.COM |
Owner |
PLEASANT HILL |
Polk |
IA |
Joel Rouse |
Shonna Rouse |
Signed |
961 |
2022-03-09 15:06 |
Anonymous (not verified) |
207.199.231.172 |
Scott Ullrick |
Proprietorship |
601 Grant St Beacon, IA 52534 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Scott Ullrick |
scottullrick@msn.com |
Beacon |
Mahaska |
IA |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Ullrick |
scottullrick@msn.com |
Self |
Beacon |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
312 |
2020-11-11 18:12 |
Anonymous (not verified) |
173.16.216.53 |
Skb transportation llc |
Limited Liability Company |
401 6th street west amana iowa 52203 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-11 |
Scott Wayne bryant |
skbtransportation@icloud.com |
West amana |
Iowa |
Iowa |
Nichole prokop |
Cory prokop |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Wayne bryant |
skbtransportation@icloud.com |
Owner |
West amana |
Iowa |
Iowa |
Nichole prokop |
Cory prokop |
Signed |
254 |
2020-09-10 20:13 |
Anonymous (not verified) |
97.127.219.61 |
Scott Woodward |
Proprietorship |
2619 west 69th 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. |
2020-09-10 |
Scott Woodward |
woodwardscott2001@gmail.com |
Davenport |
Scott |
Iowa |
Scott Woodward |
Scott Woodward |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Woodward |
woodwardscott2001@gmail.com |
Self employed |
Davenport |
Scott |
Iowa |
Scott Woodward |
Scott Woodward |
Signed |
64 |
2020-02-18 10:02 |
Anonymous (not verified) |
198.167.182.164 |
Elite Electrical Service LLC |
Limited Liability Company |
2035 Lynncrest Dr, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-18 |
Sean Brogan |
brogan_sean@hotmail.com |
Coralville |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Brogan |
brogan_sean@hotmail.com |
Managing Member |
Coralville |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
488 |
2021-04-20 13:42 |
Anonymous (not verified) |
69.63.16.2 |
STC Construction LLC |
Limited Liability Company |
329 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. |
2021-04-20 |
Sean Crane |
stc0241@gmail.com |
Riverside |
Washington |
Iowa |
Carol Glass |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Crane |
stc0241@gmail.com |
Managing Member |
Riverside |
Washingon |
Iowa |
Carol Glass |
Dyan Kriener |
Signed |
659 |
2021-09-28 11:02 |
Anonymous (not verified) |
172.58.83.48 |
Sean Goodwin |
Limited Liability Company |
8843 primrose lane 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. |
2021-09-28 |
Sean Goodwin |
simplemanmx@gmail.com |
Clive |
IA |
United States |
Kaitlyn meier |
Tina meier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Goodwin |
simplemanmx@gmail.com |
Self |
Clive |
Polk |
Iowa |
Kaitlyn meier |
Tina meier |
Signed |
1177 |
2022-07-05 10:01 |
Anonymous (not verified) |
172.58.85.103 |
Leaf Guard |
Limited Liability Partnership |
3060 SE Grimes Blvd, suite 100 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-04 |
Sean Gray |
Totaldemo94@gmail.com |
Des Moines |
Polk county |
Iowa |
Jeanie Lu |
Terra McAllister |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leaffilter North LLC |
leaffilter@leafhome.com |
Worker |
Des moines |
Polk county |
IA |
Jeanie Lu |
Terra McAllister |
Signed |
1492 |
2023-03-03 16:09 |
Anonymous (not verified) |
94.188.207.229 |
Sean Aldrich LLC |
Limited Liability Company |
408 n.7th st. 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. |
2023-03-03 |
Sean Kenneth Aldrich |
sean.aldrich74@gmail.com |
Indianola |
Warren |
Iowa |
Madeline Jenelle Aldrich |
John Thomas Aldrich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Kenneth Aldrich |
sean.aldrich74@gmail.com |
Self |
Indianola |
Warren |
Iowa |
Madeline Jenelle Aldrich |
John Thomas Aldrich |
Signed |
980 |
2022-03-16 09:38 |
Anonymous (not verified) |
207.199.231.172 |
Sean Wursta |
Proprietorship |
401 Strawberry St Eddyville, IA 52553 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-16 |
Sean Wurstra |
5wurstas@gmail.com |
Eddyville |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Self |
5wurstas@gmail.com |
self |
Mahaska |
Eddyville |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
825 |
2022-01-06 21:02 |
Anonymous (not verified) |
174.213.145.18 |
Two Brothers Tile llc |
Proprietorship |
1244 72nd 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. |
2022-01-06 |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Owner |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
17 |
2019-12-31 09:24 |
Anonymous (not verified) |
72.35.186.80 |
Grgurich Dozing & Tiling, LLC |
Partnership |
PO Box 131, Williamson, IA 50272 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-31 |
Seth Grgurich |
mcbroomt15@gmail.com |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth Grgurich |
mcbroomt15@gmail.com |
Partner |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
1644 |
2023-05-12 07:59 |
Anonymous (not verified) |
94.188.205.176 |
Blue Ribbon Drywall |
Proprietorship |
3025 Peaceful Dr 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. |
2023-05-12 |
Seth Mize Sr |
stmize@hotmail.com |
Riverside |
Washington |
Iowa |
Brad Bower |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth Mize Sr |
stmize@hotmail.com |
Self |
Riverside |
Washington |
Iowa |
Brad Bower |
Chris Hay |
Signed |
1643 |
2023-05-12 07:56 |
Anonymous (not verified) |
94.188.205.169 |
Smooth Finish Drywall |
Proprietorship |
3111 115th 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. |
2023-05-12 |
Seth T Mize II |
stmize@hotmail.com |
Riverside |
Washington |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth T Mize II |
stmize@hotmail.com |
Self |
Riverside |
Washington |
Iowa |
Chris Hay |
Brad Bower |
Signed |
421 |
2021-03-04 07:33 |
Anonymous (not verified) |
97.64.185.162 |
Malek's Lawn & Tree Service |
Proprietorship |
2535 Taft 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. |
2021-03-04 |
Shane D. Malek |
Info@Malektreeservice.com |
Garner |
Hancock |
Iowa |
Tod R. Christensen |
Saundra N. Formanek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shane D. Malek |
Info@malektreeservice.com |
Owner |
Garner |
Hancock |
Iowa |
Tod R. Christensen |
Saundra N. Formanek |
Signed |
1350 |
2022-10-31 10:42 |
Anonymous (not verified) |
108.160.48.9 |
gaes trucking |
Proprietorship |
84642 Dun Rd Norfolk, NE 68701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
SHANE GAES |
scgaes@icloud.com |
Norfolk |
NE |
United States |
Bill Rich |
Ben Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
shane gaes |
scgaes@icloud.com |
self |
norfolk |
pierce county nebraska |
nebraska |
Bill Rich |
Ben Becker |
Signed |
1561 |
2023-04-10 07:35 |
Anonymous (not verified) |
94.188.207.227 |
All season gutter |
Limited Liability Company |
1790 187th 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. |
2023-04-10 |
Shane Harold schnittjer |
allseasongutter@outlook.com |
Webster city |
Hamilton |
Iowa |
Andrea Rae schnittjer |
Shane Ethan schnittjer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shane Harold schnittjer |
allseasongutter@outlook.com |
Self |
Webster City |
Hamilton |
Iowa |
Andrea Rae schnittjer |
Shane Ethan schnittjer |
Signed |
497 |
2021-04-27 09:25 |
Anonymous (not verified) |
204.153.176.147 |
SHANE HUCK |
Proprietorship |
1070 305TH STREET, NASHUA, IOWA 50658 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-27 |
SHANE HUCK |
WOODHUCK@GMAIL.COM |
NASHUA |
CHICKASAW |
IOWA |
KIM LOECKLE |
RACHEL SCHNEIDER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHANE HUCK |
WOODHUCK@GMAIL.COM |
OWNER |
NASHUA |
CHICKASAW |
IOWA |
KIM LOECKLE |
RACHEL SCHNEIDER |
Signed |
1363 |
2022-11-08 11:37 |
Anonymous (not verified) |
69.76.241.21 |
S&M Veteran Contracting |
Proprietorship |
1529 E 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. |
2022-11-08 |
Shane Little |
smveterancontracting@gmail.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 |
Regional Recruiter |
Kansas City |
Clay |
MO |
Jordan Loyd |
Joshua Lafond |
Signed |
1896 |
2023-11-03 14:23 |
Anonymous (not verified) |
94.188.207.225 |
Shane Adams |
Limited Liability Company |
3944 54th 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. |
2023-11-03 |
Shane Steven Adams |
Shane6079@gmail.com |
Des Moines |
Polk |
Iowa |
Justin Mace |
Denice Sutton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shane Adams |
Shane6079@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Justin Mace |
Denice Sutton |
Signed |
1133 |
2022-05-29 12:39 |
Anonymous (not verified) |
75.162.116.31 |
Thompson Trades |
Limited Liability Company |
3371 200th 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. |
2022-05-29 |
shane thompson |
shane@thompsontrades.net |
prole |
IA |
IA |
Rebecca Thompson |
Denyse Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
shane thompson |
shane@thompsontrades.net |
owner |
prole |
IA |
IA |
Rebecca Ann Thompson |
Denyse Rae Thompson |
Signed |
1703 |
2023-06-23 08:58 |
Anonymous (not verified) |
94.188.205.175 |
Then & Kramer Construction, Inc |
Partnership |
P.O. Box 283 - Epworth, IA 52045 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
Shannon Kramer |
dparsons@english-insurance.com |
Epworth |
Dubuque |
Iowa |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
792 |
2021-12-14 13:18 |
Anonymous (not verified) |
173.31.148.43 |
BLUE WAVE SETTLEMENT LLC |
Limited Liability Company |
1205 H 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. |
2021-12-14 |
SHANNON NORTON |
NOERTONSHANNON@YAHOO.COM |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BLUE WAVE SETTLEMENT LLC |
NORTONSHANNON@YAHOO.COM |
SELF |
MILFORD |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
636 |
2021-09-10 14:56 |
Anonymous (not verified) |
173.19.179.111 |
SHANNON SUNDINE |
Proprietorship |
513 16TH ST 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. |
2021-09-10 |
SHANNON SUNDINE |
SPSUNDINE@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNG WIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHANNON SUNDINE |
SPSUNDINE@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
957 |
2022-03-08 14:54 |
Anonymous (not verified) |
71.39.227.238 |
Sharol Williams |
Proprietorship |
1605 Ash 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. |
2022-03-08 |
Sharol Williams |
sharolann48@gmail.com |
Dallas Center |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sharol Williams |
SharolAnn48@gmail.com |
Self |
Dallas Center |
Dallas |
Iowa |
Abbey Luellen |
Steve Phillips |
Signed |
1086 |
2022-05-03 12:32 |
Anonymous (not verified) |
173.31.148.43 |
SHAWN BAIRD |
Proprietorship |
PO BOX 44 307 MEADOW ST ROYAL, IA 51357 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
SHAWN BAIRD |
FLOORMAN3872@GMAIL.COM |
ROYAL |
CLAY |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHAWN BAIRD |
FLOORMAN3872@GMAIL.COM |
SELF |
ROYAL |
CLAY |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1432 |
2023-01-25 16:52 |
Anonymous (not verified) |
174.228.33.48 |
Thermal Tight Insulators |
Proprietorship |
1331 Linden 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. |
2023-01-25 |
Shawn Carter |
steelershawn@gmail.com |
Harlan |
Iowa |
United States |
Barbara Carter |
McKenzie carter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Carter |
steelershawn@gmail.com |
Self |
Harlan |
Iowa |
United States |
Barbara Carter |
McKenzie carter |
Signed |
2054 |
2024-02-23 10:33 |
Anonymous (not verified) |
94.188.205.175 |
Overgrown Lawn Care & Clean-Up LLC |
Limited Liability Company |
860 Main St. Stanhope, Iowa 50246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-23 |
Shawn David King |
shawndavidking@yahoo.com |
Stanhope |
Hamilton |
Iowa |
Michael Roland King |
Chrisella Ann King |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn David King |
overgrownlawn@yahoo.com |
Is Owner |
Stanhope |
Hamilton |
Iowa |
Michael Roland King |
Chrisella Ann King |
Signed |
496 |
2021-04-23 12:48 |
Anonymous (not verified) |
173.29.190.18 |
A+ Roofing and Siding Co |
Proprietorship |
1636 15th St Pl, 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. |
2021-04-22 |
SHAWN HICKS |
APLUSROOFINGQCA@YAHOO.COM |
Milan |
IL |
United States |
deena hicks |
Mike Chandler |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
SHAWN HICKS |
APLUSROOFINGQCA@YAHOO.COM |
SELF/OWNER |
Milan |
IL |
United States |
deena hicks |
Mike Chandler |
Signed |
1988 |
2024-01-16 15:22 |
Anonymous (not verified) |
94.188.205.176 |
Harmons Home Services LLC |
Limited Liability Company |
605 w Cedar st, Cherokee, IA, 51012 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Shawn Michael Harmon |
harmonsheatingandair@gmail.com |
Cherokee |
Ia |
United States |
Shawn Harmon |
Sara Harmon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Michael Harmon |
Harmonsheatingandair@gmail.com |
Self |
Cherokee |
Cherokee |
IA |
Shawn Harmon |
Sara Harmon |
Signed |
1965 |
2023-12-22 10:23 |
Anonymous (not verified) |
94.188.207.229 |
Shawn Cooney |
Proprietorship |
4425 Ne 34th 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. |
2023-12-22 |
Shawn Nelson Cooney |
shawncooney59@gmail.com |
Des Moines |
polk |
IA |
Marie Cooney |
Shawntel Cooney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Cooney |
shawncooney59@gmail.com |
Myself |
Des Moines |
polk |
IA |
Marie Cooney |
Shawntel Cooney |
Signed |
2091 |
2024-03-12 15:23 |
Anonymous (not verified) |
94.188.205.166 |
Shelley onnen |
Proprietorship |
1319 West 2nd 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. |
2024-03-12 |
Shelley L Onnen |
Shelleyonnen47@gmail.com |
PERRY |
IA |
United States |
Matthew Dean Rote |
Jerica Renae Wiborg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shelley L Onnen |
Shelleyonnen47@gmail.com |
Self |
PERRY |
IA |
United States |
Matthew Dean Rote |
Jerica Renae Wiborg |
Signed |
343 |
2020-12-28 10:46 |
Anonymous (not verified) |
173.18.204.82 |
Shelly Hildebrand |
Proprietorship |
424 E 44th St Pleasant Hill 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. |
2020-12-28 |
Shelly Hildebrand |
centraliowacleaningservice@mediacombb.net |
Pleasant Hill |
Polk |
Iowa |
Cathy Stevens |
Bailey Hildebrand |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shelly Hildebrand |
centraliowacleaningservice@mediacombb.net |
Self |
Pleasant Hill |
Polk |
Iowa |
Cathy Stevens |
Bailey Hildebrand |
Signed |
155 |
2020-05-12 17:03 |
Anonymous (not verified) |
173.17.184.241 |
Shelly Whalen |
Proprietorship |
1625 Darby Dr 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. |
2020-05-12 |
Shelly Whalen |
swhalen90@hotmail.com |
Waterloo |
IA |
United States |
Taylor Whalen |
Todd Gerleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shelly Whalen |
swhalen90@hotmail.com |
self employed |
Waterloo |
IA |
United States |
Taylor Whalen |
Todd Gerleman |
Signed |
532 |
2021-05-27 11:28 |
Anonymous (not verified) |
50.82.70.103 |
WHAT BBQ & BAR, LLC |
Limited Liability Company |
106 S CODY RD 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. |
2021-05-27 |
SHILL HUNTER |
WHATBBQBAR@GMAIL.COM |
LECLAIRE |
SCOTT |
IOWA |
WHITNEY LANE |
ROBERT CAIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHILL HUNTER |
WHATBBQBAR@GMAIL.COM |
OWNER |
LECLAIRE |
SCOTT |
IOWA |
WHITNEY LANE |
ROBERT CAIN |
Signed |
2225 |
2024-05-15 20:43 |
Anonymous (not verified) |
94.188.205.168 |
Vibrant Supported Community Living WHC |
Limited Liability Company |
1036 66th 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. |
2024-05-15 |
Shinaye Finney-EL |
Finneyel1973@icloud.com |
WINDSOR HEIGHTS |
Iowa |
United States |
Shinaye Finney-EL |
Shinaye Finney-EL |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shinaye Finney-EL |
Finneyel1973@icloud.com |
Contractor |
WINDSOR HEIGHTS |
Iowa |
United States |
Shinaye Finney-EL |
Shinaye Finney-EL |
Signed |
36 |
2020-01-15 13:26 |
Anonymous (not verified) |
173.28.28.57 |
Shirley Pepples |
Proprietorship |
206 4th Street, Parkersburg, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-14 |
Shirley Pepples |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shirley Pepples |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
260 |
2020-09-17 10:52 |
Anonymous (not verified) |
50.80.218.18 |
Decanus Property Management |
Proprietorship |
102 E 2nd St, Davenport IA 52801 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-17 |
Shonna Suzanne Dean |
decanus@yahoo.com |
Moline |
Rock Island |
Illinois |
Justin E Proctor |
Elizabeth A Oney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shonna S Dean |
decanus@yahoo.com |
Self |
Moline |
Rock Island |
Illinois |
Justin E Proctor |
Elizabeth A Oney |
Signed |
50 |
2020-02-03 14:55 |
Anonymous (not verified) |
173.28.28.57 |
Silverleaf Capital, LLC |
Limited Liability Company |
1606 Palmer Court, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-20 |
Silverleaf Capital, LLC |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Silverleaf Capital, LLC |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1019 |
2022-03-29 16:42 |
Anonymous (not verified) |
104.201.100.158 |
Nayeri Group LLC |
Limited Liability Company |
412 SE 17th Court, 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. |
2022-03-29 |
Sima Dehghan Nayeri |
nayeri.sima@gmail.com |
Grimes |
Polk |
Iowa |
Jacob Willis |
Lucas Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sima Nayeri |
nayeri.sima@gmail.com |
Self |
Grimes |
Polk |
Iowa |
Jacob Willis |
Lucas Peterson |
Signed |
708 |
2021-11-03 15:37 |
Anonymous (not verified) |
173.23.180.159 |
Simdel Enterprise LLC |
Limited Liability Company |
614 Ricker 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. |
2021-11-03 |
Simri Yonelda Aldana Leiva |
simdelenterprisellc@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares Axume |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Noemi Del Carmen Trinidad |
simdelenterprisellc@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Karla Axume |
Helmer Linares Axume |
Signed |
1284 |
2022-08-26 08:07 |
Anonymous (not verified) |
97.125.43.203 |
Sindi Merida-Alvarez dba MA Construciton LLC |
Limited Liability Company |
2048 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. |
2022-08-22 |
Sindi Merida-ALvarez |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sindi Merida- ALvarez |
deb@piciowa.com |
selk |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly Denger |
Signed |
1743 |
2023-07-13 10:24 |
Anonymous (not verified) |
94.188.207.225 |
Sindi Merida Alvarez MA Consttuction LLC |
Proprietorship |
2048 Lyon St DM, 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. |
2022-08-24 |
Sindi Merida-Alvarez dba MA Construction LLC |
deb@piciowa.com |
Des Moines |
Polk |
IA |
Debra Stratton` |
kelly Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sindi Merida Alvarez dba MA Construction LLC |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Kelly Denger |
Signed |
357 |
2021-01-12 09:56 |
Anonymous (not verified) |
173.31.147.225 |
SKYLAR INGRAHAM |
Proprietorship |
903 9TH ST 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. |
2021-01-12 |
SKYLAR INGRAHAM |
18SINGRAHA@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SKYLAR INGRAHAM |
18SINGRAHA@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1278 |
2022-08-22 12:15 |
Anonymous (not verified) |
75.162.65.221 |
Skyler Thayer |
Proprietorship |
719 34th 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. |
2022-08-22 |
Skyler Thayer |
thayerskyler@gmail.com |
West Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Skyler Thayer |
thayerskyler@gmail.com |
Self |
West Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
1243 |
2022-08-04 21:00 |
Anonymous (not verified) |
173.24.221.228 |
Foreman's Tile Creations |
Proprietorship |
1412 Franklin 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. |
2022-08-04 |
Sole Proprietor |
fudog4man@gmail.com |
Center Point |
Linn |
IA |
Aaron Foreman |
Aaron Foreman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Foreman |
fudog4man@gmail.com |
I am the Employer |
Center Point |
Linn |
IA |
Aaron Foreman |
Aaron Foreman |
Signed |
1649 |
2023-05-16 11:37 |
Anonymous (not verified) |
94.188.205.175 |
DEL-TA RESOURCE STAFFING, LLC |
Limited Liability Company |
17735 pinyon lane, Dallas TX 75252 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Solomon Solomon |
solomon@del-taresourcestaffing.com |
Dallas |
Dallas |
TX |
John Effang |
Eric Ijie |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Registered Agents Inc 315 E 5th St, STE 202 |
agent@washingtonregisteredagent.com |
Owner |
Waterloo |
Waterloo |
IA |
John Effang |
Eric Ijie |
Signed |
278 |
2020-10-09 11:25 |
Anonymous (not verified) |
174.243.82.229 |
ServTwelve7 Consulting, LLC |
Limited Liability Company |
1903 Elmhurst Avenue 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. |
2020-10-09 |
Sonya Satern |
Sonya.satern@ServTwelve7.com |
Humboldt |
Humboldt |
Iowa |
Cindy Vik |
Jill Westre |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sonya Satern |
Sonya.Satern@ServTwelve7.com |
self |
Humboldt |
Humboldt |
Iowa |
Cindy Vik |
Jill Westre |
Signed |
244 |
2020-08-25 13:32 |
Anonymous (not verified) |
97.64.194.122 |
Soren Henriksen |
Proprietorship |
2165 Roosevelt St., 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. |
2020-08-20 |
Soren Henriksen |
kschumacher@tricorinsurance.com |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Soren Henriksen |
kschumacher@tricorinsurance.com |
Same |
Dubuque |
Dubuque |
IA |
Russell Masartis |
Nancy Wortley |
Signed |
589 |
2021-07-28 16:09 |
Anonymous (not verified) |
97.125.35.240 |
Sotero Alonso Calderon Velasquez |
Proprietorship |
1312 Idaho 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. |
2021-07-26 |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
Des Moines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sotero Alonso Calderon Velazquez |
deb@piciowa.com |
subcontractor |
Des MOines |
Polk |
Iowa |
Debra Stratton |
Martin Pinon |
Signed |
238 |
2020-08-19 13:13 |
Anonymous (not verified) |
107.77.199.95 |
Southern Ag Care |
Limited Liability Company |
301 Hoover Dr |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-19 |
Southern Ag Care |
russ_buntyn@yahoo.com |
Monroe |
Ouachita |
LA |
Mark Buntyn |
Johna Buntyn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Russell Buntyn |
russ_buntyn@yahoo.com |
Owner |
Monroe |
Ouachita |
LA |
Mark Buntyn |
Johna Buntyn |
Signed |
6 |
2019-11-14 13:09 |
Anonymous (not verified) |
69.18.10.115 |
Sigourney Heating and Air Conditioning LLC |
Limited Liability Company |
106 E Washington, Sigourney Iowa 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-14 |
Spencer A Wright |
officeshac@gmail.com |
Sigourney |
Keokuk |
Iowa |
Darren Diethelm |
Myles Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer A Wright |
officeshac@gmail.com |
Owner |
Sigourney |
Keokuk |
Iowa |
Darren Diethelm |
Myles Miller |
Signed |
1995 |
2024-01-23 15:08 |
Anonymous (not verified) |
94.188.205.167 |
Spencer Abbott |
Proprietorship |
1358 170th Ave, Murray Iowa 50174 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-23 |
Spencer Abbott |
sabbott1800@gmail.com |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Abbott |
sabbott1800@gmail.com |
sole proprietor |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
951 |
2022-03-05 07:53 |
Anonymous (not verified) |
207.32.3.98 |
Larson Transport Systems |
Limited Liability Company |
3055 Maple Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-05 |
Spencer Larson |
spenlarson@gmail.com |
Forest City |
IA |
United States |
Mike Larson |
Sandy Larson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Larson |
spenlarson@gmail.com |
owner |
Forest City |
IA |
United States |
Mike Laron |
Sandy Larson |
Signed |
1351 |
2022-10-31 16:36 |
Anonymous (not verified) |
75.231.74.186 |
Spencer C Nash LLC |
Limited Liability Company |
4233 Pineview Dr 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. |
2022-10-31 |
Spencer Nash |
spencer@optionsexteriors.com |
Cedar Rapids |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Nash |
spencer@optionsexteriors.com |
Owner/Self |
Cedar Rapids |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
1908 |
2023-11-15 10:59 |
Anonymous (not verified) |
94.188.207.230 |
Snelling Construction, LLC |
Limited Liability Company |
309 Railroad Ave. 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. |
2023-11-15 |
Spencer W. Snelling |
ssnell71@yahoo.com |
Tripoili |
Bremer |
Iowa |
Michael Meyer |
Shawn Pipho |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer W. Snelling |
ssnell71@yahoo.com |
same |
Tripoli |
Bremer |
Iowa |
Michael Meyer |
Shawn Pipho |
Signed |
903 |
2022-02-07 13:46 |
Anonymous (not verified) |
173.23.176.98 |
Eccentric Electric L.L.C. |
Limited Liability Company |
206 Clark st.Evansdale Iowa 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. |
2022-02-07 |
Stacey Deutsch |
skeach@mchsi.com |
Evansdale |
BlackHawk |
Iowa |
Kelly Andrews |
Roberta Menke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacey Deutsch |
skeach@mchsi.com |
self |
Evansdae |
BlackHawk |
Iowa |
Kelly Andrews |
Roberta Menke |
Signed |
1010 |
2022-03-28 09:20 |
Anonymous (not verified) |
173.21.74.26 |
Self-employed (Stacy Davids) |
Proprietorship |
35 Lynx Lane, North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-28 |
Stacy Ann Davids |
stacyanndavids@gmail.com |
North Libery |
Johsnons |
IOWA |
Darin Gylten |
Zara Wanlass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Ann Davids |
stacyanndavids@gmail.com |
self |
North Liberty |
Johnson |
Iowa |
Darin Gylten |
Zara Wanlass |
Signed |
637 |
2021-09-10 15:15 |
Anonymous (not verified) |
204.155.61.217 |
Duwa Waterproofing LLC |
Limited Liability Company |
1548 150th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-10 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
owner |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
949 |
2022-03-04 16:09 |
Anonymous (not verified) |
173.20.147.171 |
Duwa Waterproofing LLC |
Limited Liability Company |
729 Deer view Ave, Tiffin, IA 52340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-04 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Tiffin |
Johnson |
Iowa |
Lauren Obermann |
Don Vittetoe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
owner |
Tiffin |
Johnson |
Iowa |
Lauren Obermann |
Don Vittetoe |
Signed |
954 |
2022-03-08 11:07 |
Anonymous (not verified) |
174.192.138.191 |
Duwa Waterproofing |
Limited Liability Company |
729 Deer View Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-08 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Tiffin |
Johnson |
Iowa |
Chad Cooper |
Curtis Sexton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
President |
Tiffin |
Johnson |
Iowa |
Chad Cooper |
Curtis Sexton |
Signed |
728 |
2021-11-05 14:52 |
Anonymous (not verified) |
209.252.172.87 |
Stacy Wade Wade Flooring Specialist |
Proprietorship |
2481 247th St, Washington, IA 52353 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Stacy Wade |
stacywade92@gmail.com |
Washington |
Washington |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Wade |
stacywade92@gmail.com |
Self |
Washington |
Washington |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
820 |
2022-01-03 10:41 |
Anonymous (not verified) |
174.195.193.112 |
Wolverine Construction LLC |
Limited Liability Company |
467 s 84th 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. |
2022-01-03 |
steffan sheehey |
steffanrobert@gmail.com |
West Des Moines |
Dallas |
IA |
Christopher Sheehey |
Taylor Lyman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
steffan sheehey |
steffanrobert@gmail.com |
Manager |
West Des Moines |
Dallas |
IA |
Christopher Sheehey |
Marcus Hatcher |
Signed |
1422 |
2023-01-14 10:26 |
Anonymous (not verified) |
71.39.227.238 |
Udderly Great Downtown Scoops LLC |
Limited Liability Company |
530 Walnut St, PO Box 251, 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. |
2023-01-09 |
Stephani S Jimmerson |
stephjimmerson67@gmail.com |
Minburn |
Dallas |
Iowa |
Abbey Luellen |
Laura Richardson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Don Richardson |
DonR@phillipsassociatesins.net |
Agent |
Minburn |
Dallas |
Iowa |
Abbey Luellen |
Laura Richardson |
Signed |
967 |
2022-03-11 13:41 |
Anonymous (not verified) |
205.221.255.62 |
Bard Inspection Services LLC |
Limited Liability Company |
3207 W Van Buren 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. |
2022-03-11 |
Stephanie Bard |
bardfamily4@gmail.com |
Fairfield |
Jefferson |
IA |
Miranda Millhouse |
Justin Millhouse |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Bard |
bard.inspections@gmail.com |
owner |
Fairfield |
Jefferson |
IA |
Miranda Millhouse |
Justin Millhouse |
Signed |
2206 |
2024-05-07 09:10 |
Anonymous (not verified) |
94.188.205.166 |
Stephanie Farmer |
Proprietorship |
600 6th 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. |
2024-05-07 |
Stephanie Farmer |
farmer.stephanie22@gmail.com |
Marion |
Linn |
IA |
Chris Farmer |
Deb Hartz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Farmer |
farmer.stephanie22@gmail.com |
Self |
Marion |
Linn |
IA |
Chris Farmer |
Deb Hartz |
Signed |
2180 |
2024-04-25 14:19 |
Anonymous (not verified) |
94.188.205.169 |
Stems Flower Shop, LLC |
Limited Liability Company |
515 8th St 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. |
2024-04-22 |
Stephanie Groom |
stephanie.groom@stemsiowa.com |
Altoona |
Polk |
Iowa |
Kelli Kerton |
Tyler Ingle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Groom |
stephanie.groom@stemsiowa.com |
Self - Business Owner |
Altoona |
Polk |
Iowa |
Kelli Kerton |
Tyler Ingle |
Signed |
1471 |
2023-02-20 10:24 |
Anonymous (not verified) |
94.188.205.169 |
Vega Investments |
Limited Liability Company |
330 NE 72nd Street, 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. |
2023-02-20 |
Stephanie Westrom |
stephanie.westrom@microsoft.com |
Pleasant Hill |
Polk |
Iowa |
Thomas Westrom |
Jean Schnake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Westrom |
stephanie.westrom@microsoft.com |
Owner |
Pleasant Hill |
Polk |
Iowa |
Thomas Westrom |
Jean Schnake |
Signed |
1170 |
2022-06-24 08:52 |
Anonymous (not verified) |
66.255.230.24 |
Anderson's Flying Service |
Proprietorship |
PO Box 127 Robbins, CA 95676 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Stephen Anderson |
steve@andersonsflying.com |
YUBA CITY |
CA |
United States |
Greg Foster |
Cliff Snelling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Anderson |
steve@andersonsflying.com |
Self |
YUBA CITY |
CA |
United States |
Greg Foster |
Cliff Snelling |
Signed |
162 |
2020-05-19 15:03 |
Anonymous (not verified) |
67.212.114.80 |
Collum Plumbing, LLC |
Limited Liability Company |
610 West 20th Street, 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. |
2020-05-19 |
Stephen Collum |
collumplumbing@cfu.net |
Cedar Falls |
Iowa |
United States |
Mike Thode |
Linda Thode |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Collum |
collumplumbing@cfu.net |
Member of LLC |
Cedar Falls |
Black Hawk |
Iowa |
Mike Thode |
Linda Thode |
Signed |
1657 |
2023-05-22 14:31 |
Anonymous (not verified) |
94.188.207.224 |
Collum Plumbing, LLC |
Limited Liability Company |
610 West 20th, 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. |
2023-05-22 |
Stephen Collum |
collumplumbing@cfu.net |
Cedar Falls |
Iowa |
United States |
Mike Thode |
Linda Thode |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Collum |
collumplumbing@cfu.net |
Owner/Member of LLC |
Cedar Falls |
Black Hawk |
Iowa |
Mike Thode |
Linda Thode |
Signed |
1055 |
2022-04-15 20:06 |
Anonymous (not verified) |
166.181.87.86 |
Steve MORRISON Trucking |
Proprietorship |
P.O. Box 66 105 N Elm Danville, IA 52623 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Stephen Dwight Morrison |
sdmt13@gmail.com |
Danville |
Des Mounes |
IA |
Jamie Brown |
William Samples |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Dwight Morrison |
sdmt13@gmail.com |
Owner |
Danville |
Des Moines |
IA |
Jamie Brown |
William Samples |
Signed |
1174 |
2022-06-28 07:53 |
Anonymous (not verified) |
70.39.7.208 |
SG Solid Grounds |
Proprietorship |
402 3rd Ave SE State Center Iowa 50247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-27 |
Stephen Graham |
sgsolidgrounds@gmail.com |
STATE CENTER |
IA |
United States |
Stacie Graha |
Paula Atkinson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Graham |
sgsolidgrounds@gmail.com |
Owner |
STATE CENTER |
IA |
United States |
Stacie Graham |
Paula Atkinson |
Signed |
306 |
2020-11-02 20:31 |
Anonymous (not verified) |
208.126.30.236 |
foust lawn care llc |
Limited Liability Company |
2999 st charles rd st charles ia 50240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-05 |
stephen howard foust |
shfoust53@gmail.com |
st charles |
madison |
iowa |
stephanie ann foust |
stephen wayne foust |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
stephen howard foust |
shfoust53@gmail.com |
self |
st charles |
madison |
iowa |
stephanie ann foust |
stephen wayne foust |
Signed |
30 |
2020-01-07 08:34 |
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 |
Stephen M Schauff |
steve@caricomm.com |
Dubuque |
Iowa |
IA |
Janet L Schauff |
Morris P Schauff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher R Broessel |
chris@caricomm.com |
Partner |
Dubuque |
Iowa |
IA |
Janet L Schauff |
Morris P schauff |
Signed |
207 |
2020-07-16 13:05 |
Anonymous (not verified) |
173.16.140.254 |
Steve Kennedy |
Proprietorship |
5108 SW 13th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-16 |
Steve Kennedy |
stevekennedy@gmail.com |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Kennedy |
stevekennedy007@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Jen Echterling |
Jake Hibbert |
Signed |
596 |
2021-08-04 10:48 |
Anonymous (not verified) |
184.80.177.137 |
Down Home Decor Inc |
Proprietorship |
1021 2nd Ave SE Ste 200 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. |
(1) I am not electing the employers’ liability coverage. |
2021-08-04 |
Steve Knipper |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
agent |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
1763 |
2023-07-26 12:46 |
Anonymous (not verified) |
94.188.207.224 |
Down Home Decor Inc |
Proprietorship |
1021 2nd Ave SE Ste 200 - 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. |
(1) I am not electing the employers’ liability coverage. |
2023-07-26 |
Steve Knipper |
jheims@english-insurance.com |
Dyersville |
Dubuque |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joyce Heims |
jheims@english-insurance.com |
self agent |
Dyersville |
IA |
IA |
Joyce Heims |
Derrick Parsons |
Signed |
519 |
2021-05-13 10:32 |
Anonymous (not verified) |
50.82.22.159 |
Southern Iowa Crane, Incorporated |
Proprietorship |
635 Mill Street; 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. |
2021-05-13 |
Steve Lee |
southerniowacraneinc@hotmail.com |
Ottumwa |
Wapello |
Iowa |
Brandon Gravett |
Sarah Gravett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Lee |
sotherniowacraneinc@hotmail.com |
Self |
Ottumwa |
Wapello |
Iowa |
Sarah Gravett |
Brandon Gravett |
Signed |
930 |
2022-02-20 13:24 |
Anonymous (not verified) |
174.198.77.72 |
2Maros Excavating Company |
Limited Liability Company |
204 West First Street, Saint Donatus, Iowa 52071 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-20 |
Steve Maro |
2marosmfg@gmail.com |
Saint Donatus |
Jackson |
Iowa |
Brenda McKenna |
Joe McKenna |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Maro |
2marosmfg@gmail.com |
Owner |
Saint Donatus |
Jackson |
Iowa |
Brenda McKenna |
Joe McKenna |
Signed |
1016 |
2022-03-29 14:26 |
Anonymous (not verified) |
104.145.202.155 |
S.M.Trucking |
Proprietorship |
3270 Hwy 69 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Steve Miller |
S.M.Trucking52@gmail.com |
3270 Hwy 69 Forest City |
Hancock |
Ia |
Julie Miller |
Amy Picha |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Miller |
S.M.Trucking52@gmail.com |
Owner |
3270 Hwy 69 Forest City |
Hancock |
Ia |
Julie Miller |
Amy Picha |
Signed |
654 |
2021-09-24 15:08 |
Anonymous (not verified) |
199.247.64.87 |
Steve Porter DBA Precision Striping |
Proprietorship |
408 Embassy Ct. Sergeant Bluff, IA 51054 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-23 |
Steve Porter |
steve.porter2710@gmail.com |
Sergeant Bluff |
Woodbury |
Iowa |
Josh Nichols |
Steve Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jana Reich |
JNeuzil@reichpainting.com |
Office Manager |
Sioux City |
Woodbury |
Iowa |
Josh Nichols |
Steve Porter |
Signed |
2075 |
2024-03-05 22:32 |
Anonymous (not verified) |
94.188.207.225 |
Steve Roland Trucking LLC |
Limited Liability Company |
2141 Wadsley 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. |
2024-03-05 |
Steve Roland |
roland.farms@yahoo.com |
Sac City |
IA |
United States |
Caylee Hoffard |
Kristen Wirtjers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Roland |
roland.farms@yahoo.com |
Owner/Member |
Sac City |
IA |
United States |
Caylee Hoffard |
Kristen Wirtjers |
Signed |
2076 |
2024-03-05 22:38 |
Anonymous (not verified) |
94.188.207.229 |
Steve Roland Trucking LLC |
Limited Liability Company |
2141 Wadsley 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. |
2024-03-05 |
Steve Roland |
roland.farms@yahoo.com |
Sac City |
Sac |
Iowa |
Caylee Hoffard |
Kristen Wirtjers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Roland |
roland.farms@yahoo.com |
Owner/Member |
Sac City |
Sac |
Iowa |
Caylee Hoffard |
Kristen Wirtjers |
Signed |
959 |
2022-03-09 10:30 |
Anonymous (not verified) |
207.199.231.172 |
Steve Shepherd |
Proprietorship |
332 N Walnut St Fremont, IA 52561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Steve Shepherd |
sheps2s69@gmail.com |
Fremont |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Shepherd |
sheps2s69@gmail.com |
Self |
Fremont |
Mahaska |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
904 |
2022-02-08 08:11 |
Anonymous (not verified) |
173.23.180.117 |
Dawg House Renovation |
Limited Liability Company |
113 Allen St 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. |
2022-02-08 |
Steve Sprague |
dawghouse729@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Paula Sprague |
Stewart Sprague |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Sprague |
dawghouse729@Gmail.Com |
Self |
Waterloo |
Black Hawk |
Iowa |
Paula Sprague |
Stewart Sprague |
Signed |
1631 |
2023-05-09 10:13 |
Anonymous (not verified) |
94.188.207.229 |
Steve Stratton |
Proprietorship |
208 SE 5th St 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. |
2023-04-01 |
Steve Stratton |
deb@piciowa.com |
Grimes |
Polk |
Iowa |
Debra Stratton |
Kenneth Stratton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Stratton |
deb@piciowa.com |
self |
Grimes |
Polk |
Iowa |
Debra Stratton |
Kenneth Stratton |
Signed |
1654 |
2023-05-19 11:09 |
Anonymous (not verified) |
94.188.205.176 |
ST SULLIVAN CONSTRUCTION COMPANY |
Proprietorship |
1614 100TH ST., OELWEIN, 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. |
2023-05-19 |
STEVE SULLIVAN |
sullycon@msn.com |
Oelwein |
Fayette |
Iowa |
Bobbie J Bergan |
Shelby Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
STEVE SULLIVAN |
sullycon@msn.com |
OWNER |
OELWEIN |
FAYETTE |
IOWA |
BOBBIE J BERGAN |
SHELBY WILLIAMS |
Signed |
571 |
2021-07-12 09:51 |
Anonymous (not verified) |
67.55.237.31 |
Steve Vogel |
Proprietorship |
314 NE 2ND ST. Panora, Iowa 50216-2020 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-12 |
Steve Vogel |
thevogels@netins.net |
PANORA |
Guthrie |
United States |
Diana Vogel |
Adam Vogel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Vogel |
thevogels@netins.net |
Self |
PANORA |
Guthrie |
Iowa |
Diana Vogel |
Adam Vogel |
Signed |
1685 |
2023-06-12 07:21 |
Anonymous (not verified) |
94.188.207.224 |
Steven Boshart |
Proprietorship |
2172 Scales Bend Road Northeast, North Liberty, IA 52317, 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. |
2023-06-12 |
Steven Boshart |
sboshart1982@gmail.com |
North Liberty, MO |
Johnson |
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 Wood |
Jordan Loyd |
Signed |
655 |
2021-09-24 15:28 |
Anonymous (not verified) |
67.212.111.166 |
S Miller Painting LLC |
Limited Liability Company |
1135 Barnett Drive, 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. |
2021-09-24 |
Steven David Miller |
stevendm24@hotmail.com |
Cedar Falls |
Black Hawk |
Iowa |
Steve Koger |
Mark Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Allen koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Black Hawk |
Iowa |
Steve Koger |
Mark Miller |
Signed |
1399 |
2022-12-22 08:40 |
Anonymous (not verified) |
45.16.156.93 |
Valley Five, LLC DBA L & N Docks and Lifts |
Limited Liability Company |
9523 W 151st Ter Overland Park, KS 66221 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Steven Dolezal |
steven.w.dolezal@gmail.com |
Overland Park |
Johnson |
Kansas |
Joan Dolezal |
Kelsey Dolezal |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Dolezal |
steven.w.dolezal@gmail.com |
Owner |
Overland Park |
Johnson |
Kansas |
Joan Dolezal |
Kelsey Dolezal |
Signed |
291 |
2020-10-25 11:06 |
Anonymous (not verified) |
208.126.69.94 |
self-employed |
Proprietorship |
PO Box 15, 430 E. Iowa 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. |
2022-10-25 |
Steven Fisher |
fishersjk@gmail.com |
St. Mary's |
Iowa |
United States |
Jodi Fisher |
Jenna Fisher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Fisher |
fishersjk@gmail.com |
same person |
St. Mary's |
Iowa |
United States |
Jodi Fisher |
Jenna Fisher |
Signed |
1789 |
2023-08-08 13:18 |
Anonymous (not verified) |
94.188.207.230 |
Corridor Construction Co., LLC |
Limited Liability Company |
P.O. Box 8540 Cedar Rapids, IA 52408 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Steven H. Miller |
jimfortmann60@gmail.com |
Cedar Rapids |
Linn |
IA |
James J. Fortmann |
Ruth Ann Beers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven H. Miller |
jimfortmann60@gmail.com |
Member |
Cedar Rapids |
Linn |
IA |
James J. Fortmann |
Ruth Ann Beers |
Signed |
549 |
2021-06-25 16:19 |
Anonymous (not verified) |
165.225.57.46 |
Shaw Livestock, LLC |
Limited Liability Company |
6871 275th Street, Moravia, IA 52571-8003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2021-06-25 |
Steven H. Shaw |
steve@shawlivestock.com |
Moravia |
Appanoose |
Iowa |
Scott Saveraid |
Alexa Sheeder |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Steven Shaw |
steve@shawlivestock.com |
Self |
Moravia |
Appanoose |
Iowa |
Scott Saveraid |
Alexa Sheeder |
Signed |
256 |
2020-09-14 09:38 |
Anonymous (not verified) |
66.188.136.150 |
Steven Headlee |
Proprietorship |
671 Metaire Drive Apt. A, Greenwood, IN 46143 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-14 |
Steven Headlee |
kschumacher@tricorinsurance.com |
Greenwood |
Johnson |
IN |
Nancy Wortley |
Russell Masartis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Headlee |
kschumacher@tricorinsurance.com |
Same |
Greenwood |
Johnson |
IN |
Nancy Wortley |
Russell Masartis |
Signed |
833 |
2022-01-12 17:30 |
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 |
Steven John Swanson |
studio7sjs@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 Koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Braden L Gray |
Signed |
1072 |
2022-04-26 16:17 |
Anonymous (not verified) |
166.182.80.187 |
N & S Trucking Inc |
Limited Liability Company |
3061 170Th 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. |
2022-04-26 |
Steven Kirk Van Ommen |
Stevevo74@yahoo.com |
Riverside |
Iowa |
United States |
Steve Van Ommen |
Steve Van Ommen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Kirk Van Ommen |
Stevevo74@yahoo.com |
President |
Riverside |
IA |
United States |
Steve Van Ommen |
Steve Van Ommen |
Signed |
141 |
2020-04-28 10:14 |
Anonymous (not verified) |
74.84.101.138 |
Lutheran Cemetery Association |
Proprietorship |
410 S. Mechanic 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. |
2020-03-02 |
Steven Matter |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Bobbi Jo Berg |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Matter |
chelsea.whalen@upperiowains.com |
Secretary |
Decorah |
Winneshiek |
IA |
BOBBI JO BERG |
Robin C Schultz |
Signed |
422 |
2021-03-05 13:53 |
Anonymous (not verified) |
71.39.227.238 |
Steven Phillips |
Proprietorship |
1107 Walnut 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. |
2021-03-06 |
Steven Phillips |
stevep@phillipsassociatesins.net |
Linden |
Guthrie |
Iowa |
Abbey Luellen |
RoseMary Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Phillips |
stevep@phillipsassociatesins.net |
Self |
Linden |
Guthrie |
Iowa |
RoseMary Phillips |
Abbey Luellen |
Signed |
295 |
2020-10-28 15:19 |
Anonymous (not verified) |
72.46.55.242 |
SAI'S RENTALS LLC |
Limited Liability Company |
637 S ANKENY BLVD, 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. |
2020-10-28 |
SUMEET SEHGAL |
saisrentals.avisbudget@gmail.com |
ANKENY, IA |
POLK |
IOWA |
CLINT LILIENTHAL |
DIANNE KELLE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SUMEET SEHGAL |
saisrentals.avisbudget@gmail.com |
SELF |
ANKENY |
POLK |
IOWA |
CLINT LILIENTHAL |
DIANNE KELLE |
Signed |
829 |
2022-01-11 11:03 |
Anonymous (not verified) |
173.22.78.156 |
Marr Arnold Planning, LLC |
Limited Liability Company |
1328 California Ave, Ames, IA 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. |
2022-01-11 |
Summer Marr |
summer@marrarnoldplanning.com |
Ames |
Story |
IA |
Beth Skluzacek |
Kris Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Summer Marr |
summer@marrarnoldplanning.com |
owner |
Ames |
Story |
IA |
Beth Skluzacek |
Kris Evans |
Signed |
917 |
2022-02-16 09:48 |
Anonymous (not verified) |
167.142.86.212 |
Susan A Cunningham |
Proprietorship |
3409 Stone City Rd, 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. |
(1) I am not electing the employers’ liability coverage. |
2022-02-16 |
Susan A Cunningham |
2oldrabbits@gmail.com |
Central City |
Linn |
Iowa |
Donna Zimmerman |
Norm Zimmerman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Susan A Cunningham |
2oldrabbits@gmail.com |
self |
Central City |
Linn |
Iowa |
Donna Zimmerman |
Norm Zimmerman |
Signed |
1532 |
2023-03-24 18:05 |
Anonymous (not verified) |
94.188.205.174 |
Crafty Dome LLC |
Limited Liability Company |
3524 Stonebridge 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. |
2023-03-24 |
Susan Bernau |
craftydome@yahoo.com |
West Des Moines |
Polk |
Iowa |
George Cummins |
Linda Green |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Susan Bernau |
craftydome@yahoo.com |
owner |
3524 Stonebridge Rd |
Polk |
Iowa |
George Cummins |
Linda Green |
Signed |
1448 |
2023-02-10 16:55 |
Anonymous (not verified) |
94.188.205.177 |
Marks Nursery LLC |
Limited Liability Company |
15008 310th Trl, 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. |
2023-02-10 |
Susan L Jones |
sljoines026@gmail.com |
Redfield |
Dallas |
Iowa |
Douglas Jones |
Caitlin Zimmerman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Donald Richardson |
DonR@phillipsassociatesins.net |
Agent |
Redfield |
Dallas |
Iowa |
Douglas Zimmerman |
Caitlin Zimmerman |
Signed |
1799 |
2023-08-14 14:42 |
Anonymous (not verified) |
94.188.205.174 |
Magiclean |
Proprietorship |
2001 S. 16th Burlington Iowa 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. |
2023-08-14 |
Sydney Bornsheuer |
Mistycale@gmail.com |
Burlington |
Iowa |
Iowa |
Dustina Fenton |
Doug Shupick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Misty Cale |
magicleanburlington@gmail.com |
Owner |
Burlington |
Des Moines |
Iowa |
Dustina Fenton |
Doug Shupick |
Signed |
735 |
2021-11-11 14:10 |
Anonymous (not verified) |
72.13.16.172 |
T MILLER TRUCKING LLC |
Limited Liability Company |
1682 MONROE 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. |
2019-11-18 |
T MILLER TRUCKING LLC |
DAVE@ALLSEASONSTRUCKING.COM |
WATERVILLE |
ALLAMAKEE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
T MILLER TRUCKING LLC |
dave@allseasonstrucking.com |
PRESIDENT |
WATERVILLE |
ALLAMAKEE |
IA |
Dave Neuwohner |
BEN MOYER |
Signed |
337 |
2020-12-11 21:56 |
Anonymous (not verified) |
66.129.217.166 |
Tabora Perez Minerva |
Proprietorship |
4494 Taft Ave SE Trl. 1B 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. |
2020-12-01 |
Tabora Perez Minerva |
tonypauljohnson@yahoo.com |
Iowa City |
Johnson |
Iowa |
Anthony Johnson |
Rafael Donis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tabora Perez Minerva |
tonypauljohnson@yahoo.com |
Agent |
Iowa City |
Johnson |
IA |
Anthony Johnson |
Rafael Donis |
Signed |
474 |
2021-04-13 12:09 |
Anonymous (not verified) |
65.103.82.36 |
Helfrich Construction |
Proprietorship |
1327 Garnet St. Burlington 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. |
2019-04-29 |
Tad Helfrich |
littlet20012001@yahoo.com |
Burlington |
Des Moines |
IA |
Teresa Helfrich |
Ron Helfrich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tad Helfrich |
littlet20012001@yahoo.com |
owner |
Burlington |
Des Moines |
IA |
Teresa Helfrich |
Ron Helfrich |
Signed |
79 |
2020-02-25 17:28 |
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 |
Tamara Glendenning |
lanceandabby@wccta.net |
Davis Junction |
Ogle |
Il |
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 |
419 |
2021-03-03 13:52 |
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 |
Tamara Glendenning |
lanceandabby@wccta.net |
Davis Junction |
Ogle |
Illinois |
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 |
974 |
2022-03-14 18:04 |
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 |
Tamara Glendenning |
happysower4@gmail.com |
Davis Junction |
Ogle |
Illinois |
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 |
92 |
2020-03-13 15:53 |
Anonymous (not verified) |
173.24.190.134 |
Tammy Sabin |
Limited Liability Company |
112 Miller Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-09 |
Tammy Sabin |
sales@smalltownrv.com |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tammy Sabin |
sales@smalltownrv.com |
Member of LLC |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
1495 |
2023-03-06 09:57 |
Anonymous (not verified) |
94.188.207.224 |
Midwest Indoor Air Quality, LLC |
Limited Liability Company |
701 NE Brook Haven Drive, 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. |
2023-03-06 |
Tanner Evan Francisco |
tanner.midwestindoorairquality@outlook.com |
Ankeny |
IA |
United States |
Sherry Reynolds |
David Boyer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Midwest Indoor Air Quality, LLC |
tanner.midwestindoorairquality@outlook.com |
Same |
Ankeny |
IA |
United States |
Sherry Reynolds |
David Boyer |
Signed |
229 |
2020-08-11 14:42 |
Anonymous (not verified) |
75.162.158.159 |
Tanner Bruellman |
Limited Liability Company |
205 NE 25th ct grimes, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-11 |
Tanner George Bruellman |
bruellmantan_1@hotmail.com |
Grimes |
Poll |
Iowa |
Mary Kathleen Bruellman |
Andrew Bruellman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mary Kathleen Bruellman |
bruellmantan_1@hotmail.com |
Wife |
Grimes |
Polk |
Iowa |
Mary Kathleen Bruellman |
Andrew James Bruellman |
Signed |
1125 |
2022-05-25 06:36 |
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 |
Tanya Van De Stroet |
Accounting@inwoodfeeders.com |
Inwood |
Lyon |
Iowa |
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 |
138 |
2020-04-28 10:10 |
Anonymous (not verified) |
74.84.101.138 |
Nisse Preschool & Kids Place |
Partnership |
311 College Drive 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. |
2020-02-26 |
Tasha Sibley |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tasha Sibley |
chelsea.whalen@upperiowains.com |
Secretary |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
1771 |
2023-08-01 09:59 |
Anonymous (not verified) |
94.188.207.223 |
Modern Builder LLC |
Limited Liability Company |
30008 560th St Chariton IA 50049 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-01 |
Tatyana Sayenko |
modernbuilder02@gmail.com |
Chariton |
Lucas |
Iowa |
Arthur Sayenko |
Viktor Sayenko |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tatyana Sayenko |
modernbuilder02@gmail.com |
owner/ Family |
Chariton |
Lucas |
Iowa |
Arthur Sayenko |
Viktor Sayenko |
Signed |
387 |
2021-02-08 14:26 |
Anonymous (not verified) |
192.30.185.142 |
Go 2 Girls |
Proprietorship |
104 Doral Lane, Dakota Dunes, SD 57049 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Tawnya Oneill |
tawny5881@gmail.com |
Dakota Dunes |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tawnya Oneill |
tawny5881@gmail.com |
Owner |
Dakota Dunes |
Union |
SD |
Katie Jenks |
Virginia Anderson |
Signed |
2170 |
2024-04-22 10:11 |
Anonymous (not verified) |
94.188.207.224 |
Joy Ride Transport |
Limited Liability Company |
3105 SE Miehe Drive, 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. |
2024-04-22 |
Ted Cochran |
ted@ridejoyride.com |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ted Cochran |
ted@ridejoyride.com |
Self |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |