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Nonelection of Workers' Compensation or Employers' Liability Coverage

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# Submitted User IP address Name of Employer: Type of Entity: Address of Employer's Home Office: Statement 1 Agreement: Statement 2 Agreement: Statement 3 Agreement: Understanding Confirmation: Check Either Alternative (1) or (2): Date: Full Name of Individual: Email: City of Residence: County of Residence: State of Residence: Full Name of Witness 1: Full Name of Witness 2: Signing Indication: Check either alternative (1) or (2): Full Name of Authorized Agent: Email of Authorized Agent: Relationship to Employer of Authorized Agent: City of Residence: County of Residence: State of Residence: Full Name of Witness No. 1: Full Name of Witness No. 2: Signing Indication:
436 2021-03-16 13:37 Anonymous (not verified) 141.193.221.33 Custom Applicationz Partnership 13220 Hwy S70 Plano, IA 52581 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-16 Zebulun Joiner joinerconst@gmail.com Plano Appanoose IA Danielle Joiner Zebulun Joiner Signed (1) The employer does not elect the employers’ liability coverage. Danielle Joiner joinerconst@gmail.com Self/Wife of Partner Plano Appanoose IA Zebulun Joiner Danielle Joiner Signed
1446 2023-02-08 16:49 Anonymous (not verified) 94.188.207.228 ZAHID ALI Limited Liability Company 3245 SOUTHGATE PL SW, 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. 2023-02-10 ZAHID ALI ali@americaninncid.com CEDAR RAPIDS USA IOWA ZAHID ALI ZAHID ALI Signed (1) The employer does not elect the employers’ liability coverage. ZAHID ALI ali@americaninncid.com self cedar rapids usa iowa ZAHID ALI ZAHID ALI Signed
1770 2023-07-31 14:21 Anonymous (not verified) 94.188.205.168 D & G Communications Proprietorship 405 1st St N., PO Box 11 Farley, Iowa 52046 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-31 Dave Hirsch dngcomm@hotmail.com Farley Dubuque Iowa Zack Hirsch Nick Hirsch Signed (1) The employer does not elect the employers’ liability coverage. Dave Hirsch dngcomm@hotmail.com self Farley Dubuque Iowa Zach Hirsch Nick Hirsch Signed
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
12 2019-12-17 19:54 Anonymous (not verified) 50.83.188.192 B & B Construction Proprietorship 2463 93rd Avenue Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-17 Brock A Maxwell brock246393@gmail.com Des Moines IA United States Hope Winegardner Yvonne Ginther Signed (1) The employer does not elect the employers’ liability coverage. Brock A Maxwell brock246393@gmail.com Owner Des Moines POlK Iowa Yvonne Ginther Hope Winegardner Signed
1070 2022-04-26 09:35 Anonymous (not verified) 174.198.72.171 Boyz Roofing LLC Limited Liability Company 802 E County Lane Rd Lot 25 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-26 Cupertino Rodriguez Hernandez christopherrodriguez091889@gmail.com Des Moines Polk Iowa Yoselin Morales Manny Sokop Signed (1) The employer does not elect the employers’ liability coverage. Cupertino Rodriguez Hernandez christopherrodriguez091889@gmail.com Owner Des Moines Polk Iowa Yoselin Morales Manny Sokop Signed
554 2021-07-01 15:54 Anonymous (not verified) 75.162.212.130 Avila Gutters Inc Proprietorship 5901 sw 5th st Des Moines IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-24 Enrique Avila enrique86avila@gmail.com Des moines polk iowa Yolanda Mendoza Lilliana Sanchez Signed (1) The employer does not elect the employers’ liability coverage. Enrique Avila enrique86Avila@gmail.com owner des moines polk iowa yolanda mendoza liliana sanchez Signed
620 2021-08-26 16:26 Anonymous (not verified) 75.162.146.246 Daniel Meza Reyes Proprietorship 1640 E Army Post RD Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-23 Daniel Meza Reyes danielmr9247@gmail.com Des Moines polk IA Yolanda Mendoza Liliana Sanchez Signed (1) The employer does not elect the employers’ liability coverage. Daniel Meza Reyes danielmr9247@gmail.com self Des Moines polk IA Yolanda Mendoza Liliana Sanchez Signed
672 2021-10-13 16:05 Anonymous (not verified) 75.162.218.218 Arturos Interiors LLC Limited Liability Company 3305 se 22nd apt 15 Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-29 Arturo mejia arturomcruz20@hotmail.com Des Moines polk IA yolanda mendoza liliana sanchez Signed (1) The employer does not elect the employers’ liability coverage. Arturo Mejia arturomcruz20@hotmail.com member Des Moines polk IA Yolanda Mendoza lialiana sanchez Signed
675 2021-10-15 11:22 Anonymous (not verified) 75.162.156.37 MCG FLOORING, LLC Limited Liability Company 2115 CARPENTER AVE DES MOINES IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-15 GABRIELA GOMEZ MCGFLOORINGLLC@GMAIL.COM DES MOINES USA IA YOLANDA MENDOZA LILIANA SANCHEZ GUTIERREZ Signed (1) The employer does not elect the employers’ liability coverage. MCG FLOORING, LLC MCGFLOORINGLLC@GMAIL.CON OWNER DES MOINES USA IA YOLANDA MENDOZA LILIANA SANCHEZ GUTIERREZ Signed
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
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
1984 2024-01-15 17:33 Anonymous (not verified) 94.188.207.227 Jay Wang Limited Liability Company 8481 Birchwood Ct, Johnston I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-15 Jay Wang jaywang@wasabidsm.com Clive US IA Yingna Zheng Qiaoqiao Li Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang jaywang@wasabidsm.com Self Clive US IA Yingna Zheng Qiaoqiao Li Signed
1991 2024-01-17 00:34 Anonymous (not verified) 94.188.207.223 Wasabi urbandale llc Limited Liability Company 7115 Ridgedale 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. 2024-01-17 Wenhui chen michaelchen@wasabidsm.com Johnston Polk Iowa Yilian lin Ji jie jie Signed (1) The employer does not elect the employers’ liability coverage. Wenhui chen michaelchen@wasabidsm.com Owner Johnston Polk Iowa Yilian lin Ji jie jie 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
1330 2022-10-11 10:59 Anonymous (not verified) 24.252.38.219 XXX Limited Liability Company XXX I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-15 XXX XXX@gmail.com XX XXX XXX XXX XXX Signed (1) The employer does not elect the employers’ liability coverage. XXX XXX@gmail.com XXX XXX XXX XXX XXX XXX Signed
2062 2024-02-29 08:25 Anonymous (not verified) 94.188.205.169 Midwest Splicing LLC Limited Liability Company 1803 N HALF BANK RD , Stringtown , OK 74569 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-29 James Xiong midwestsplicing71@yahoo.com Stringtown OKLAHOMA OKLAHOMA Vang Pao Chang Xia Vang Signed (1) The employer does not elect the employers’ liability coverage. James Xiong midwestsplicing71@yahoo.com owner STRINGTOWN Oklahoma Oklahoma xia Vang Vang Pao Chang Signed
310 2020-11-09 13:32 Anonymous (not verified) 75.89.78.93 CA Smith LLC Limited Liability Company 805 N Hayes Street Mount Ayr, Iowa 50854 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-01 CA Smith LLC smithoil.cs@gmail.com Mount Ayr Ringgold Iowa Wm H French Deborah Creveling Signed (1) The employer does not elect the employers’ liability coverage. CA Smith LLC smithoil.cs@gmail.com Self Mount Ayr Ringgold Iowa Wm H French Deborah Creveling Signed
226 2020-08-07 11:37 Anonymous (not verified) 71.39.227.238 Clinton Luellen Proprietorship 18591 N Ave, Minburn, IA 50167 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-07 Clinton Luellen CALuellen@gmail.com Minburn Dallas Iowa Winette Luellen Don Richardson Signed (1) The employer does not elect the employers’ liability coverage. Clinton Luellen CALuellen@gmail.com Self Minburn Dallas Iowa Winette Luellen Don Richardson Signed
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
1145 2022-06-07 11:14 Anonymous (not verified) 173.30.72.62 Swifty Enterprises Limited Liability Company 1134 Capri Drive NE, Cedar Rapids, IA 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-07 Daniel Tabaka dmtabaka1@gmail.com Cedar Rapids Linn IA Wilma Janacek Fredrick Janacek Signed (1) The employer does not elect the employers’ liability coverage. Daniel Tabaka dmtabaka1@gmail.copm Self Cedar Rapids Linn IA Wilma Janacek Fredrick Janacek Signed
2070 2024-03-01 10:21 Anonymous (not verified) 94.188.205.167 J&W siding LLC Limited Liability Company 302 West Lincoln 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. 2024-03-01 william t Belz 5.4tritonf150@gmail.com Walcott IA IA william t Belz william t Belz Signed (1) The employer does not elect the employers’ liability coverage. william t Belz 5.4tritonf150@gmail.com owner Walcott IA IA william t Belz william t Belz Signed
1549 2023-03-30 14:22 Anonymous (not verified) 94.188.205.166 BILL MASSENGALE TRUCKING LLC Limited Liability Company 4583 100TH 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 WILLIAM MASSENGALE BLMASSE31@GMAIL.COM MONTEZUMA Iowa United States Lori Massengale Brianna Massengale Signed (1) The employer does not elect the employers’ liability coverage. Lori MASSENGALE BLMASSE31@GMAIL.COM Spouse MONTEZUMA Iowa United States WILLIAM MASSENGALE Brianna MASSENGALE Signed
1043 2022-04-12 18:20 Anonymous (not verified) 66.129.218.53 DON'S LOCK & SAFE LLC Proprietorship 4223 YVETTE ST SUITE 101, IOWA CITY, IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-12 BRIAN E LOUGH LOLOCK@LIVE.COM NORTH LIBERTY JOHNSON IOWA WILLIAM H CRILE KELLI L SCOTT Signed (1) The employer does not elect the employers’ liability coverage. BRIAN E LOUGH LOLOCK@LIVE.COM OWNER NORTH LIBERTY JOHNSON IA WILLIAM H CRILE KELLI L SCOTT Signed
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
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
395 2021-02-12 15:05 Anonymous (not verified) 173.28.7.235 Brad Neff Limited Liability Company 5431 gear 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. 2021-02-12 Wesley Detman wesdet@gmail.com Des moines Iowa United States Leah Laxton Wesley Detman Signed (1) The employer does not elect the employers’ liability coverage. All pro painting, LLC Brad@allpropaintingdsm.com Self Prole Warren Iowa Wesley Detman Leah Laxton Signed
396 2021-02-12 15:05 Anonymous (not verified) 173.28.7.235 Brad Neff Limited Liability Company 5431 gear 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. 2021-02-12 Wesley Detman wesdet@gmail.com Des moines Iowa United States Leah Laxton Wesley Detman Signed (1) The employer does not elect the employers’ liability coverage. All pro painting, LLC Brad@allpropaintingdsm.com Self Prole Warren Iowa Wesley Detman Leah Laxton Signed
397 2021-02-12 15:05 Anonymous (not verified) 173.28.7.235 Brad Neff Limited Liability Company 5431 gear 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. 2021-02-12 Wesley Detman wesdet@gmail.com Des moines Iowa United States Leah Laxton Wesley Detman Signed (1) The employer does not elect the employers’ liability coverage. All pro painting, LLC Brad@allpropaintingdsm.com Self Prole Warren Iowa Wesley Detman Leah Laxton Signed
398 2021-02-12 15:05 Anonymous (not verified) 173.28.7.235 Brad Neff Limited Liability Company 5431 gear 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. 2021-02-12 Wesley Detman wesdet@gmail.com Des moines Iowa United States Leah Laxton Wesley Detman Signed (1) The employer does not elect the employers’ liability coverage. All pro painting, LLC Brad@allpropaintingdsm.com Self Prole Warren Iowa Wesley Detman Leah Laxton Signed
1935 2023-12-02 18:34 Anonymous (not verified) 94.188.207.229 Wasabi Johnston LLC Limited Liability Company 8184 Birchwood Ct, Johnston IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-02 Jay Wang jaywang@wasabidsm.com Clive Dallas IA Engjin zheng yingna Zheng Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang jaywang@wasabidsm.com self Clive Dallas IA Wenhui Cheng Enjing Zheng Signed
1931 2023-12-01 18:01 Anonymous (not verified) 94.188.207.225 Jay Wang Limited Liability Company 16672 Verona Hills Dr, Clive IA 50325 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-01 Jay Wang jaywang@wasabidsm.com Clive US IA WenHui chen Yingna Zheng Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang Jaywang@wasabidsm.com Self Clive US IA WenHui Chen Yingna Zheng Signed
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
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
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
603 2021-08-14 09:39 Anonymous (not verified) 173.20.168.51 Leaf Filter Proprietorship 3060 Southeast Grimes Boulevard I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-08-14 Francisco Salgado fsalgado1989@gmail.com Perry IA United States Wendy Asturias Susana Romero Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Leaf Filter macosta@leafhome.com none Grimes Polk Iowa Wendy Asturias Susana Romero Signed
1934 2023-12-01 22:43 Anonymous (not verified) 94.188.207.224 wasabi johnston llc Limited Liability Company 7115 ridgedale ct, johnston, IA, 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-01 wenhui chen michaelchen@wasabidsm.com johnston polk Iowa wen Zheng Jenna Yu Signed (1) The employer does not elect the employers’ liability coverage. wenhui chen michaelchen@wasabidsm.com owner johnston polk IOWA wen zheng Jenna Yu Signed
1952 2023-12-12 13:26 Anonymous (not verified) 94.188.205.167 Austin Albin Proprietorship 2263 Railroad Street, Jacksonville, IL 62650 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-23 Austin R Albin albinaustin12@gmail.com Jacksonville Morgan IL Wayne Albin Jerry Roth Signed (1) The employer does not elect the employers’ liability coverage. Austin R Albin albinaustin12@gmail.com Self Jacksonville Morgan IL Wayne Albin Jerry Roth Signed
940 2022-03-01 11:08 Anonymous (not verified) 216.51.251.31 trent montgomery trucking llc Limited Liability Company 1432 eagle ridge circle 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. 2022-03-01 trent montgomery trent.montgomery7@gmail.com pierce pierce nebraska warren montgomery travis montgomery Signed (1) The employer does not elect the employers’ liability coverage. trent montgomery trent.montgomery7@gmail.com self pierce pierce nebraska warren douglas montgomery travis warren montgomery Signed
610 2021-08-18 11:15 Anonymous (not verified) 172.58.84.99 LeafFilter North LLC Partnership 866 40th ave bettendorf iowa 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-18 Thomas R Fuller tomstl001@yahoo.com DAVENPORT Iowa Iowa Bob phillips Julie fuller Signed (1) The employer does not elect the employers’ liability coverage. Jordan nisiewicz jnisiewicz@leafhome.com Regional field recruiter Bettendorf iowa Scott Iowa Warren crow Jordan lloyd Signed
176 2020-06-07 08:23 Anonymous (not verified) 174.16.51.128 TrueFood LLC Limited Liability Company 2055 Nature Ave Stanton IA 51573 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-24 Brian Barkman brian.barkman@truefood.farm Georgetown Williamson Texas Wanda Barkman Chelsea Church Signed (1) The employer does not elect the employers’ liability coverage. Brian Barkman brian.barkman@truefood.farm TrueFood LLC is owned by agent Stanton Montgomery IA Wanda Barkman Chelsea Church Signed
62 2020-02-17 06:55 Anonymous (not verified) 173.31.111.29 Pa's Construction LLC Limited Liability Company 2350 Glass Rd NE, Cedar Rapids, IA 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-17 Gregory Daniel Saunders gsaunders.pas@gmail.com CEDAR RAPIDS IOWA United States Laura Sturm Chad Johnson Signed (1) The employer does not elect the employers’ liability coverage. Daniel Saunders dan2112411@yahoo.com Owner Cedar Rapids Linn Iowa Walt Cheney Mike Broghammer Signed
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
653 2021-09-23 15:03 Anonymous (not verified) 72.46.189.33 Feldkamp Farms Inc Partnership 5382 170th St Sibley IA 51249 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-23 Harold P Feldkamp joan@ellerbroekandassociates.com Sibley IA United States Wade Ellerbroek Jr Joan Wallace Signed (1) The employer does not elect the employers’ liability coverage. James Wade Ellerbroek Jr WADE@ELLERBROEKANDASSOCIATES.COM Agent only Sibley IA United States Wade Ellerbroek Jr Joan Wallace Signed
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
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
2195 2024-04-30 15:31 Anonymous (not verified) 94.188.205.166 Jason Cooper Proprietorship 1181 Western Ave Stockton Iowa 52769 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-30 Jason cooper jvcpainting88@gmail.com Stockton IA United States Violet minssen Hope Bishop Signed (1) The employer does not elect the employers’ liability coverage. Jason cooper jvcpainting88@gmail.com Self Stockton IA United States Violet minssen Hope Bishop Signed
2117 2024-03-27 10:38 Anonymous (not verified) 94.188.207.226 ALCON CONSTRUCTION LLC Limited Liability Company 2613 GINDY DR, BELLEVUE, NE 68147 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 VALERIE OLONO ALCONCONSTRUCTION2021@GMAIL.COM BELLEVUE SARPY NEBRASKA VICTOR H OLONO GANDARILLA ALEXANDRA GUTIERREZ Signed (1) The employer does not elect the employers’ liability coverage. VALERIE OLONO ALCONCONSTRUCTION2021@GMAIL.COM SELF BELLEVUE SARPY NEBRASKA VICTOR H OLONO GANDARILLA ALEXANDRA GUTIERREZ 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
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
639 2021-09-13 16:10 Anonymous (not verified) 50.81.97.207 Copic Home Maintenance LLC dba Des Moines Drywall Repair Limited Liability Company 1548 24th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-13 Clint R Copic crcopic@gmail.com Des Moines Polk Iowa Veronica G. Torres Dan Waidelich Signed (1) The employer does not elect the employers’ liability coverage. Clint R Copic dmdrywallrepair@gmail.com self Des Moines Polk Iowa Veronica G Torres Dan Waidelich Signed
393 2021-02-11 12:36 Anonymous (not verified) 173.21.130.224 Ashby Roofing Proprietorship 3307 Clearwater dr Bettendorf I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-11 Thomas Ashby Tashby8@aol.com Bettendorf Scott Iowa Veronica Ashby Tommy Ashby Signed (1) The employer does not elect the employers’ liability coverage. United Insurance Counslers Tashby8@aol.com owner Bettendorf Scott Iowa Veronica Ashby Tommy Ashby Signed
830 2022-01-11 16:18 Anonymous (not verified) 173.29.117.19 Leaf filter Proprietorship 866 40th ave Bettendorf, Iowa 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-11 Tom Ashby tashby8@aol.com Bettendorf Scott County IA Veronica Ashby Natalie Ashby Signed (1) The employer does not elect the employers’ liability coverage. Adam Coleman arcoleman@leafhome.com Work coordinator Bettendorf Scott IA Veronica Ashby Tom Ashby Signed
1101 2022-05-13 12:55 Anonymous (not verified) 174.199.102.54 Daniel Blanco Proprietorship 1403 2nd Ave S I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-13 Daniel Blanco chindan77@yahoo.com Ft Dodge Webster IA Vanessa Blanco Elva Castañeda Signed (1) The employer does not elect the employers’ liability coverage. Daniel Blanco chindan77@yahoo.com Self Ft Dodge Webster IA Vanessa Blanco Elva Castañeda Signed
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
926 2022-02-17 15:20 Anonymous (not verified) 166.181.83.68 Staley Trucking LLC Limited Liability Company 1388 140th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-17 Travis Staley staleyracing121@gmail.com Hampton Franklin IA Tyler Staley Jeff Staley Signed (1) The employer does not elect the employers’ liability coverage. Travis Staley staleyracing121@gmail.com President Hampton Franklin IA Tyler Staley Jeff Staley Signed
1779 2023-08-03 15:40 Anonymous (not verified) 94.188.207.224 Action Garage Builders Limited Liability Company 1635 Kerry Lane, Jesup, IA 50648 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-03 Brady Huls brady.cve@gmail.com Cedar Falls Black Hawk Iowa Tyler Reynolds Joshua Carder Signed (1) The employer does not elect the employers’ liability coverage. Troy Even actiongaragebuilders@gmail.com Owner Jesup Buchanan Iowa Tyler Reynolds Joshua Carder Signed
1400 2022-12-22 10:02 Anonymous (not verified) 166.196.110.105 It's a Breeze Cleaning Service Proprietorship 760 W 8th Ave Marion, IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-22 Breonna Nelson breanderson82@yahoo.com Marion Linn Iowa Tyler Nelson Lisa Nelson Signed (1) The employer does not elect the employers’ liability coverage. Breonna Nelson Breanderson82@yahoo.com Self Marion Linn IA Tyler Nelson Lisa Nelson Signed
1466 2023-02-17 15:12 Anonymous (not verified) 94.188.207.230 BIG Roofing, LLC Limited Liability Company 5751 NE 22nd St. #304 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 Tyler Jeffrey Baugh tj@bigroofing515.com Lincoln Lancaster Nebraska Steven Bieghler Andrew John Kohles Signed (1) The employer does not elect the employers’ liability coverage. Steven Craig Bieghler steve@bigroofing515.com Owner Cumming Dallas Iowa Tyler Jeffrey Baugh Andrew John Kohles Signed
2080 2024-03-07 12:57 Anonymous (not verified) 94.188.205.168 Will's Bus Stuff LLC Limited Liability Company 402 SE Grant 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. 2024-03-07 Will Boettcher wboettcher@centurionstoneofiowa.com Des Moines Iowa United States Tyler Franklin Troy Klein Signed (1) The employer does not elect the employers’ liability coverage. Will Boettcher willsbusstuffllc@gmail.com Owner Ankeny Iowa United States Tyler Franklin Troy Klein 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
2214 2024-05-08 13:49 Anonymous (not verified) 94.188.205.168 Hagen Installation Solutions LLC Limited Liability Company 725 Cole St Carlisle, IA 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-08 Clay Allen Hagen clay.hagenson@gmail.com Carlisle Warren Iowa Tyler Bumgardner Spencer Kissinger Signed (1) The employer does not elect the employers’ liability coverage. Clay Allen Hagen clay.hagenson@gmail.com Same person Carlisle Warren Iowa Tyler Bumgardner Spencer Kissinger 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
779 2021-12-06 10:43 Anonymous (not verified) 172.83.21.144 Munn Enterprises LLC Limited Liability Company 118 14th Avenue South I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-06 Douglas A Munn munnent1328@gmail.com Clear lake IA IA Troy Thomas Munn Marjorie Marie Munn Signed (1) The employer does not elect the employers’ liability coverage. Troy Munn Troy@munnentllc.com Owner Clear Lake Cerro Gordo Iowa Troy Thomas Munn Marjorie Marie Munn Signed
259 2020-09-16 15:44 Anonymous (not verified) 174.243.82.6 Freedom Maintenance Services LLC Limited Liability Company 1633 2nd St Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-16 Cole Keith McDonald cole.freedomservices@outlook.com Boone Boone IA Troy Thomas Graen Kurtis Joseph Wendl Signed (1) The employer does not elect the employers’ liability coverage. Cole Keith McDonald cole.freedomservices@outlook.com Me Boone Boone IA Troy Thomas Graen Kurtis Joseph Wendl Signed
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
1007 2022-03-25 10:30 Anonymous (not verified) 208.73.53.194 Cory Lehman Proprietorship 2428 Keokuk Drive Pella, IA 50219 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-25 Cory Lehman corysfloors@hotmail.com Pella Marion Iowa Trisha K Klok Terri Van Ryswyk Signed (1) The employer does not elect the employers’ liability coverage. Cory Lehman corysfloors@hotmail.com Self Pella Marion Iowa Trisha K Klok Terri Van Ryswyk Signed
212 2020-07-20 16:43 Anonymous (not verified) 97.64.164.30 Bernard L. Gradoville D.D.S. Proprietorship 2800 Ingersoll Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-20 Bernard Gradoville bgradoville@ingersollfamilydentistry.com Des Moines IA United States Tricia Wilson Jack Gradoville Signed (1) The employer does not elect the employers’ liability coverage. Bernard Gradoville bgradoville@ingersollfamilydentistry.com self Des Moines IA United States Tricia Wilson Jack Gradoville Signed
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
1116 2022-05-17 21:41 Anonymous (not verified) 75.162.182.172 Hinds Metal Designs LLC Limited Liability Company 11409 Dakota St, Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-18 Brad Hinds bahinds@msn.com Norwalk Iowa Iowa Trevor Masten Travis Masten Signed (1) The employer does not elect the employers’ liability coverage. Carlene Hinds carlene4082@msn.com Self Norwalk Iowa Iowa Trevor Masten Travis Masten Signed
1096 2022-05-12 15:47 Anonymous (not verified) 64.64.128.230 Tim Woslager Limited Liability Company 612 West 8th St Neligh Ne 68756 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Tim Woslager timwoslager@icloud.com Neligh Antelope NE Trent Montgomery Travis Montgomery Signed (1) The employer does not elect the employers’ liability coverage. Tim Woslager timwoslager@icloud.com Owner Neligh Antelope NE Trent Montgomery Travis Montgomery Signed
1097 2022-05-12 15:47 Anonymous (not verified) 64.64.128.230 Tim Woslager Limited Liability Company 612 West 8th St Neligh Ne 68756 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Tim Woslager timwoslager@icloud.com Neligh Antelope NE Trent Montgomery Travis Montgomery Signed (1) The employer does not elect the employers’ liability coverage. Tim Woslager timwoslager@icloud.com Owner Neligh Antelope NE Trent Montgomery Travis Montgomery Signed
1105 2022-05-16 13:40 Anonymous (not verified) 174.235.192.160 Travis Montgomery Trucking LLC Limited Liability Company 701 N 4th street Plainview Ne 68769 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-16 Travis Montgomery travismontgomery76@gmail.com Plainview Pierce Nebraska Tim Woslager Trent Montgomery Signed (1) The employer does not elect the employers’ liability coverage. Travis Montgomery Trucking LLC travismotgomery76@gmail.com Owner Plainview Pierce Nebraska Trent Montgomery Tim woslager Signed
1106 2022-05-16 13:40 Anonymous (not verified) 174.235.192.160 Travis Montgomery Trucking LLC Limited Liability Company 701 N 4th street Plainview Ne 68769 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-16 Travis Montgomery travismontgomery76@gmail.com Plainview Pierce Nebraska Tim Woslager Trent Montgomery Signed (1) The employer does not elect the employers’ liability coverage. Travis Montgomery Trucking LLC travismotgomery76@gmail.com Owner Plainview Pierce Nebraska Trent Montgomery Tim woslager Signed
956 2022-03-08 13:56 Anonymous (not verified) 72.13.16.196 Naprstek Media LLC Limited Liability Company 6505 Wellington Ln, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-08 James Naprstek jimmy@kodiakcreative.com Dubuque Dubuque Iowa Trent Hanselmann Jonathan O'Brien Signed (1) The employer does not elect the employers’ liability coverage. Cheyenne Moseley services@e.legazoom.com Authorized Agent Glendale Los Angeles CA Trent Hanselmann Jonathan O'Brien Signed
1540 2023-03-29 07:55 Anonymous (not verified) 94.188.205.175 Adaptive Wildlife Management Limited Liability Company 18306 120th 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. 2023-03-29 Travis Strable tstrable@hotmail.com Indianola Iowa United States Travis Strable Travis Strable Signed (1) The employer does not elect the employers’ liability coverage. Travis Strable tstrable@hotmail.com owner Indianola Iowa United States Travis Strable Travis Strable Signed
1562 2023-04-10 07:43 Anonymous (not verified) 94.188.205.174 JB Concrete and Construction Limited Liability Company 306 1st Ave N.W Dayton Ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-10 JaredBerglund jaredberglund71@gmail.com Dayton Webster Iowa Travis Sonksen Chase Haman Signed (1) The employer does not elect the employers’ liability coverage. JaredBerglund jaredberglund71@gmail.com Owner Dayton Webster Iowa Travis Sonksen Chase Haman Signed
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
1521 2023-03-16 14:26 Anonymous (not verified) 94.188.207.229 Mmk electric Partnership 4515 84th st Urbandale ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-16 Elijah dale kain mmk.iowa@gmail.com West Des moines Polk Iowa Travis Lee miller Marshall Logan McKay Signed (1) The employer does not elect the employers’ liability coverage. Travis Lee miller mmk.iowa@gmail.com Owner Urbandale Polk Iowa Travis Lee miller Marshall Logan mckay Signed
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
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
1406 2023-01-04 11:58 Anonymous (not verified) 67.55.135.18 Duncan Home Services LLC Limited Liability Company 2543 Cottage Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-04 Alethea Anne Duncan projects@duncanhs.com Waverly IA United States Travis Duncan Kristine Fisher Signed (1) The employer does not elect the employers’ liability coverage. Travis Duncan projects@duncanhs.com spouse Waverly IA United States Travis Duncan Kristine Fisher Signed
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
271 2020-09-27 20:30 Anonymous (not verified) 173.17.8.56 Hutch's Parking Lot Sweeping Inc Limited Liability Company 5235 Jennifer 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. 2020-09-27 William E Hutchinson Jr btnwhutch@aol.com Pleasant Hill Polk Iowa Tracy Hutchinson Diana Benda Signed (1) The employer does not elect the employers’ liability coverage. William E Hutchinson Jr btnwhutch@aol.com Self Pleasant Hill Polk Iowa Tracy Hutchinson Diana Benda Signed
1352 2022-10-31 19:35 Anonymous (not verified) 173.17.8.56 Hutch's Parking Lot Sweeping INC Limited Liability Company 5235 JENNIFER DR I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-31 Bill HUTCHINSON btnwhutch@aol.com PLEASANT HILL Iowa United States TRACY HUTCHINSON NIC HUTCHINSON Signed (1) The employer does not elect the employers’ liability coverage. Bill HUTCHINSON btnwhutch@aol.com SELF PLEASANT HILL Iowa United States TRACY HUTCHINSON NIC HUTCHINSON Signed
1156 2022-06-15 18:25 Anonymous (not verified) 173.18.137.166 Talaska Trucking Proprietorship 1626 byron ave. waterloo iowa 50702 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-15 Don Talaska dtalaska83@gmail.com WATERLOO Black Hawk Iowa Traci Talaska Reese Talaska Signed (1) The employer does not elect the employers’ liability coverage. Don Talaska dtalaska83@gmail.com Owner WATERLOO Black Hawk iowa Traci Talaska Reese Talaska Signed
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
309 2020-11-09 12:17 Anonymous (not verified) 70.184.213.31 Gerald Gerhardt Proprietorship 104 S 3rd Street, Villisca, IA 50864 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-03 Gerald Gerhardt jerrygerhardt1280@gmail.com Villisca Montgomery IA Tony W. Johnson Gerald Gerhardt Signed (1) The employer does not elect the employers’ liability coverage. Smith Davis Insurance tony@smithdavisins.com Client Papillion Sarpy IA Tony W. Johnson Gerald Gerhardt Signed
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
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
1360 2022-11-04 11:13 Anonymous (not verified) 50.81.34.190 Rescue 365 Towing & Salvage Limited Liability Company 2569 58th 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. 2022-11-04 Tyler Schwartz rescue365@hotmail.com VAN HORNE Benton IA Tony Harmon Tracy Beitz Signed (1) The employer does not elect the employers’ liability coverage. Tyler Schwartz rescue365@hotmail.com Self Van Horne Benton IA Tony Harmon Tracy Beitz Signed
1622 2023-05-01 16:05 Anonymous (not verified) 94.188.205.174 Danny Shineflew Proprietorship 103th 10street West Des Moines I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-01 Danny Shineflew dannyshineflew@gmail.com West Des Moines Polk Iowa Tony Ekman Dustin Hogan Signed (1) The employer does not elect the employers’ liability coverage. Danny Shineflew dannyshineflew@gmail.com self West Des Moines Polk Iowa Tony Ekman Dustin Hogan Signed
1543 2023-03-29 15:37 Anonymous (not verified) 94.188.207.225 Sulzner Construction LLC Limited Liability Company 210 N CHERRY ST, PO BOX 264 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-29 Aksel C Sulzner akselsmoke@gmail.com Mechanicsville IA United States Toni Pollard Phil Rouse Signed (1) The employer does not elect the employers’ liability coverage. Aksel C Sulzner akselsmoke@gmail.com Self Mechanicsville IA United States Toni Pollard Phil Rouse Signed
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
1699 2023-06-22 07:36 Anonymous (not verified) 94.188.205.175 V2E Advisors LLC Limited Liability Company 701 Lakeview Ct, 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. 2023-06-22 Tyler Rhamy trhamy@v2eadvisors.com Tiffin Iowa United States Tasha Rhamy Tom Rhamy Signed (1) The employer does not elect the employers’ liability coverage. Tyler Rhamy trhamy@v2eadvisors.com Member / President Tiffin Johnson Iowa Tom Rhamy Tasha Rhamy Signed
1062 2022-04-20 06:46 Anonymous (not verified) 38.121.112.209 Cabinets and Closets by Design LLC Limited Liability Company 18409 250th Street, 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. 2022-04-18 Timothy Slobodnik cabinetsandclosetsbydesign@gmail.com Council Bluffs Pottawattamie IA Tom Pieper Jim Sietsema Signed (1) The employer does not elect the employers’ liability coverage. Timothy Slobodnik cabinetsandclosetsbydesign@gmail.com self Council Bluffs Pottawattamie IA Tom Pieper Jim Sietsema 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
761 2021-11-22 07:22 Anonymous (not verified) 73.211.163.27 James crockett Limited Liability Company 417 easr st south Kewanee il 61443 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-22 James crockett tattoojec@gmail.com Kewanee il Henery Il Tom mcintire Colton english Signed (1) The employer does not elect the employers’ liability coverage. Hog city construction tattoojec@gmail.com Self Kewanee Henery Il Tom mcintire Colon english Signed
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
1780 2023-08-03 16:50 Anonymous (not verified) 94.188.207.230 S-N-T BRINKMAN TRANSFER LLC Proprietorship 401 East Dewey Street Cassville, WI 53806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-01 Todd A Brinkman sntbrink@hotmail.com Cassville Wisconsin Wisconsin Todd A Brinkman Todd A Brinkman Signed (1) The employer does not elect the employers’ liability coverage. Todd A Brinkman sntbrink@hotmail.com Self employed Cassville Wisconsin Wisconsin Todd Brinkman Todd Brinkman 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
1515 2023-03-13 15:04 Anonymous (not verified) 94.188.207.226 Flint Hillman Proprietorship 1019 E 17th St, APT 16, Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-13 Flint Hillman flinthillman@gmail.com Norwalk Warren Iowa Tina Robinson Paige Robinson Signed (1) The employer does not elect the employers’ liability coverage. Flint Hillman flinthillman@gmail.com Self Norwalk Warren Iowa Tina Robinson Paige Robinson Signed
1163 2022-06-23 09:17 Anonymous (not verified) 74.84.106.106 James Chitty Proprietorship 307 2nd St Colo, Ia 50056 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 James Chitty techsupport@smartind.com Colo Story IA Tina Owens Kim Owens Signed (1) The employer does not elect the employers’ liability coverage. James Chitty techsupport@smartind.com self Colo Story IA Tina Owens Kim Owens Signed
1166 2022-06-23 09:44 Anonymous (not verified) 74.84.106.106 alan squires Proprietorship 702 2nd ave sw #4 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 alan squires shanesq411@gmail.comm altoona polk iowa TIna Owens Rita Littell Signed (1) The employer does not elect the employers’ liability coverage. alan squires shanesq411@gmail.com self altoona polk iowa Tina Owens Rita Littell Signed
1167 2022-06-23 09:56 Anonymous (not verified) 74.84.106.106 Adam Wamsher Proprietorship 1517 Ridge Crest Ct Knoxville, IA 50138 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 Adam Wamsher wamshera@hotmail.com Knoxville Marion Iowa Tina Owens Kim Owens Signed (1) The employer does not elect the employers’ liability coverage. Adam Wamsher wamshera@hotmail.com Self Knoxville Marion Iowa Tina Owens Kim Owens Signed
1168 2022-06-23 12:57 Anonymous (not verified) 74.84.106.106 dora valadez Proprietorship 1244 e 32 nd st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 dora valadez towens@smartind.com Des Moines Polk Iowa Tina Owens Kim Owens Signed (1) The employer does not elect the employers’ liability coverage. dora valadez towens@smartind.com self Des Moines Polk Iowa Tina Owens Kim Owens Signed
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
1591 2023-04-21 13:59 Anonymous (not verified) 94.188.207.226 Self employed Proprietorship 406 s main prairie city I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-21 Thomas Leo carroll Tom.carroll66@gmail.com Prairie city Jasper Iowa Tina hellyer Matt wenthie Signed (1) The employer does not elect the employers’ liability coverage. Tom carroll Tom.carroll66@gmail.com Self Prairie city Jasper Iowa Tina hellyer Matt whinthy Signed
1294 2022-09-04 18:09 Anonymous (not verified) 38.121.112.25 Cabinets and Closets by Design LLC Limited Liability Company 18409 250th Street, 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. 2022-09-04 TIMOTHY SLOBODNIK cabinetsandclosetsbydesign@gmail.com COUNCIL BLUFFS IA United States Jim Sietsema Jeff Deramcy Signed (1) The employer does not elect the employers’ liability coverage. TIMOTHY SLOBODNIK cabinetsandclosetsbydesign@gmail.com self COUNCIL BLUFFS IA United States TIMOTHY SLOBODNIK TIMOTHY SLOBODNIK Signed
1414 2023-01-07 22:14 Anonymous (not verified) 38.121.112.25 Cabinets and Closets by Design LLC Proprietorship 18409 250th Street, 430 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-07 TIMOTHY SLOBODNIK cabinetsandclosetsbydesign@gmail.com COUNCIL BLUFFS IA United States Jim Sietsema Jeff Deramcy Signed (1) The employer does not elect the employers’ liability coverage. TIMOTHY SLOBODNIK cabinetsandclosetsbydesign@gmail.com self COUNCIL BLUFFS IA United States TIMOTHY SLOBODNIK TIMOTHY SLOBODNIK 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
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
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
1080 2022-04-29 08:59 Anonymous (not verified) 216.51.225.18 Lee's Haul It & Property Care Proprietorship 212 Village Dr #5, 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. 2022-04-29 Tim Lee timclee160@gmail.com Tiffin Johnson Iowa Lee Krueger Aaron Oehring Signed (1) The employer does not elect the employers’ liability coverage. Lee's Haul It & Property Care leeshaulit@gmail.com Owner Tiffin Johnson Iowa Tim Lee Aaron Oehring 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
1486 2023-02-26 17:53 Anonymous (not verified) 94.188.205.177 TURNER LAWN CARE Limited Liability Company 16493 185th Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-27 JEFF TURNER jscturner2626@gmail.com MILO IA United States Tim Borrall BONNIE BORRALL Signed (1) The employer does not elect the employers’ liability coverage. SHARON RENEE TURNER jscturner2626@gmail.com wife MILO IA United States Tim Borrall BONNIE BORRALL Signed
894 2022-02-04 11:18 Anonymous (not verified) 152.117.105.90 Dusty schraceo Proprietorship 712 E 15th St Davenport, IA, 52803 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-04 Dusty Schraceo dustyschraceo1999@gmail.com Davenport Scott Iowa Tiffani Branham Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Dusty Schraceo dustyschraceo1999@gmail.com Self Davenport Scott Iowa Tiffani Branham Cody Dunbar Signed
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
2213 2024-05-08 13:37 Anonymous (not verified) 94.188.205.174 Timothy strong Limited Liability Company 615 61street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Timothy Dewayne strong jr timothystrong33@gmail.com Davenport iowa USA Iowa Thomasina hunter Tyletha dates Signed (1) The employer does not elect the employers’ liability coverage. Timothy strong painting timothystrong33@gmail.com Friend Davenport Usa Iowa Thomasina hunter Tyletha dates 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
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
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
1299 2022-09-07 14:55 Anonymous (not verified) 167.142.60.66 Harleen Trenching Proprietorship 2066 X Ave, Madrid Iowa 50156 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Bill Harleen sandyharleen@hotmail.com Madrid Boone Iowa Thomas H Andersen Dustin T Andersen Signed (1) The employer does not elect the employers’ liability coverage. Bill Harleen Harleentrenching@hotmail.com Self Madrid Boone Iowa Thomas H Andersen Dustin T Andersen Signed
1711 2023-06-26 16:50 Anonymous (not verified) 94.188.207.224 Innovative Behavioral Therapy, LLC Limited Liability Company 915 Main St. Adel IA 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-26 Ashley Andrew ashley@innovativebehavioraltherapy.com Adel Dallas Iowa Thomas Atherton Brenda Barto Signed (1) The employer does not elect the employers’ liability coverage. Ashley Andrew ashley@innovativebehavioraltherapy.com Self Adel Dallas Iowa Thomas Atherton Brenda Barto Signed
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
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
2165 2024-04-19 14:05 Anonymous (not verified) 94.188.207.225 Apex Striping LLC Limited Liability Company 1325 Western Ave, cedar Falls, IA. 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-19 Chaz Ernest Torres admin@apexstripingia.com Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed (1) The employer does not elect the employers’ liability coverage. Chaz Ernest Torres admin@apexstripingia.com Self Cedar Falls Blackhawk Iowa Theresa Jo Torres Eloy James Torres Signed
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
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
2223 2024-05-14 16:16 Anonymous (not verified) 94.188.205.168 Test Proprietorship test I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-14 Test User aaron.staker@dia.iowa.gov Test Test Test Test Witness Test Witness 2 Signed (1) The employer does not elect the employers’ liability coverage. Testing aaron.staker@dia.iowa.gov Testing Testing Testing Testing Testing Witness 1 Testing Witness 2 Signed
32 2020-01-08 08:31 Anonymous (not verified) 199.120.118.90 BOBCATS LLC Limited Liability Company 1860 505TH ST LINN GROVE IOWA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 CHRIS AXDAHL CHRISAXDAHLINC@HOTMAIL.COM LINN GROVE CLAY IOWA TESSA L STEFFEN JOSEPH E ZENKOVICH Signed (1) The employer does not elect the employers’ liability coverage. CHRIS AXDAHL CHRISAXDAHLINC@HOTMAIL.COM OWNER LINN GROVE CLAY IOWA TESSA L STEFFEN JOSEPH E ZENKOVICH Signed
1710 2023-06-26 16:10 Anonymous (not verified) 94.188.207.226 Adaptability Plus 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. 2023-06-26 Timothy Combs timcombs@afiliowa.org Waterloo Iowa United States Teresa Tjaden Mark Moser Signed (1) The employer does not elect the employers’ liability coverage. Mark Moser mpmmoser@gmail.com PARTNER WATERLOO Black Hawk Iowa TERSEA TJADEN TIM COMBS Signed
354 2021-01-11 15:04 Anonymous (not verified) 71.199.85.251 Heather Hampton Cooper Consulting, llc Limited Liability Company 412 Mango Cir, Saint Augustine, Florida 32095 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-11 Heather H Cooper hcooper1@comcast.net Saint Augustine Saint Johns FL Terry l. Cooper Lauren Rivera Signed (1) The employer does not elect the employers’ liability coverage. Heather H Cooper hcooper1@comcast.net Owner Saint Augustine Saint Johns FL Terry Cooper Lauren Rivera Signed
1477 2023-02-23 11:45 Anonymous (not verified) 94.188.205.166 Earl Woods DBA Solar Solutions Proprietorship 1328 42nd St Des Moines IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-23 Earl Woods solarsolutions_1@msn.com Des Moines Polk Iowa Terrie Woods Tracy Day Signed (1) The employer does not elect the employers’ liability coverage. Earl Woods solarsolutions_1@msn.com wife Des Moines Polk IA Terrie Woods Tracy Day Signed
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
1421 2023-01-13 09:43 Anonymous (not verified) 96.18.190.183 Home Base Inspection & Code Services, LLC Limited Liability Company 3805 Ridge Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-13 Amanda Harper amanda@hbicsvs.com Sioux City IA United States Terri Harper Joy Brouilette Signed (1) The employer does not elect the employers’ liability coverage. Amanda Harper amanda@hbicsvs.com self Sioux City IA United States Terri Harper Joy Brouillette Signed
947 2022-03-04 11:20 Anonymous (not verified) 165.225.61.42 Timothy Peyton Proprietorship 865 Bentley Dr Unit 23, 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. 2022-03-04 Timothy Peyton theaton@amfam.com Marion Linn IA Terra Heaton Kari Benore Signed (1) The employer does not elect the employers’ liability coverage. Timothy Peyton theaton@amfam.com self Marion Linn IA Terra Heaton Kari Benore Signed
1603 2023-04-25 20:42 Anonymous (not verified) 94.188.205.174 Nursepro Staffing Agency Limited Liability Company 8450 Hickman Rd suite A2 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-04-25 Teresiah muchemi nurseproagency@gmail.com desmoines polk iowa Teresiah Muchemi John Waweru Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Teresiah Muchemi nurseproagency@gmail.com Owner desmoines Polk iowa Teresiah Muchemi John Waweru 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
1695 2023-06-19 06:54 Anonymous (not verified) 94.188.207.224 Leaf Filter Proprietorship 3060 SE Grimes Blvd Unit 100 Grimes, IA 50111 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. 2023-06-17 Trenton Finch tjfinch10@gmail.com Kellogg Jasper Iowa Teagan Kruse Diane Finch Signed (1) The employer does not elect the employers’ liability coverage. Trenton Finch tjfinch10@gmail.com Subcontractor Kellogg Jasper Iowa Teagan Kruse Diane Finch 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
1715 2023-06-28 09:48 Anonymous (not verified) 94.188.207.229 Charles westbrook Limited Liability Company 2374 31st a Moline I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-06-28 Charles Micheal westbrook Westbrook.69.mw@gmail.com Moline USA Illinois Taylor Davis N/a Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Charles Micheal Westbrook Westbrook.69.mw@gmail.com Gf Moline IL United States Taylor davis N/a Signed
1265 2022-08-17 11:10 Anonymous (not verified) 166.181.81.66 Balvanz Electric Proprietorship 1517 Greenfield Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-17 Brent Balvanz balvanzelectric@gmail.com Marshalltown Iowa Iowa Tawnya Dawson Phyllis Mazour Signed (1) The employer does not elect the employers’ liability coverage. Brent Balvanz balvanzelectric@gmail.com Self Marshalltown Iowa Iowa Tawnya Dawson Phyllis Mazour Signed
1266 2022-08-17 11:10 Anonymous (not verified) 166.181.81.66 Balvanz Electric Proprietorship 1517 Greenfield Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-17 Brent Balvanz balvanzelectric@gmail.com Marshalltown Iowa Iowa Tawnya Dawson Phyllis Mazour Signed (1) The employer does not elect the employers’ liability coverage. Brent Balvanz balvanzelectric@gmail.com Self Marshalltown Iowa Iowa Tawnya Dawson Phyllis Mazour Signed
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
1889 2023-11-01 06:44 Anonymous (not verified) 94.188.207.226 Williams Hardwood Flooring LLC Limited Liability Company P.O. Box 22 Marion, Ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-01 Chad Everett William williamshardwoodflooringllc@gmail.com Anamosa Jones IA Tara Williams Sarah Williams Signed (1) The employer does not elect the employers’ liability coverage. Chad E Williams williamsharfwoodflooringllc@gmail.com Me Anamosa Jones IA Tara Williams Sarah Williams Signed
1023 2022-03-31 10:34 Anonymous (not verified) 173.23.251.188 Thede Home Improvement Proprietorship 1940 86th St Windsor Heights, IA 50324 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-31 Cameron Thede camthede22@gmail.com Windsor Heitghts Polk IA Tara Murphy Mike Ryerson Signed (1) The employer does not elect the employers’ liability coverage. Cameron Thede camthede22@gmail.com owner Windsor Heights Polk IA Tara Murphy Mike Ryerson Signed
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
1025 2022-04-01 09:32 Anonymous (not verified) 173.23.251.188 Dakota Lester Proprietorship 2711 Cedar St Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-01 Dakota Lester dlester18@icloud.com Norwalk Warren Iowa Tara Murphy Mike Ryerson Signed (1) The employer does not elect the employers’ liability coverage. Dakota Lester dlester18@icloud.com owner Norwalk Warren Iowa Tara Murphy Mike Ryerson Signed
1054 2022-04-15 15:05 Anonymous (not verified) 173.23.251.188 Integrity Design & Development, LLC Limited Liability Company 810 NW Logan St Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-15 Jerry Houk integrity.design.development@gmail.com Ankeny Polk Iowa Tara Murphy Mike Ryerson Signed (1) The employer does not elect the employers’ liability coverage. Integrity Design & Development, LLC integrity.design.development@gmail.com owner Ankeny Polk Iowa Tara Murphy Mike Ryerson Signed
1141 2022-06-03 08:15 Anonymous (not verified) 173.23.251.188 SP Exteriors, LLC Limited Liability Company 804 Philip 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. 2022-06-03 Travis Espey tespey48@gmail.com Des Moines Polk IA Tara Murphy Mike Ryerson Signed (1) The employer does not elect the employers’ liability coverage. Travis Espey tespey48@gmail.com owner Des Moines Polk IA Tara Murphy Mike Ryerson Signed
1253 2022-08-12 14:43 Anonymous (not verified) 173.23.251.188 GLBH, LLC Proprietorship 3396 268th St Linden, IA 50146 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-12 Gavin Lamb gavinglbh@outlook.com Linden Guthrie IA Tara Murphy Nick Stevens Signed (1) The employer does not elect the employers’ liability coverage. Gavin Lamb gavinglbh@outlook.com self Linden Guthrie IA Tara Murphy Nick Stevens Signed
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
1337 2022-10-17 13:07 Anonymous (not verified) 173.23.251.188 Dr. Dom Home Repair LLC Limited Liability Company 503 Cedar Ave, Woodward IA. 50276 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-17 Dominique Forest drdomhomerepair@gmail.com Woodward Dallas Iowa Tara Murphy Mike Ryerson Signed (1) The employer does not elect the employers’ liability coverage. Dominique L Forest drdomhomerepair@gmail.com Owner/operator Woodward Dallas Iowa Tara Murphy Marc Badeaux Signed
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
1851 2023-09-22 12:36 Anonymous (not verified) 94.188.207.229 MNM Construction Proprietorship 3224 sw 12th place des moines iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-22 craig allen mccormick craigmccormick.6363@gmail.com Des Moines Iowa Iowa Tara Murphy Kristie Hubbard Signed (1) The employer does not elect the employers’ liability coverage. craig mccormick craigmccormick.6363@gmail.com self Des Moines Iowa Iowa Tara Murphy Kristie Hubbard Signed
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
464 2021-04-07 22:15 Anonymous (not verified) 173.18.251.105 TEMPLEMAN LAWN CARE AND SNOW REMOVAL Proprietorship 1612 Lomas 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. 2021-04-07 TIM LEE Templeman nancytempleman@gmail.com Atlantic IA United States TARA JESSEN ALFRED WEDE Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. CULLEN AND ASSOCIATES tammy@cullenins.com Insurance agent Atlantic Cass Iowa Tara Jessen Alfred Wede Signed
465 2021-04-07 22:24 Anonymous (not verified) 173.18.251.105 TEMPLEMAN LAWN CARE Proprietorship 1612 Lomas Cr. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-01 Tim Lee Templemn nancytempleman@gmail.com Atlantic Iowa United States Tara Jessen Alfred Wede Signed (1) The employer does not elect the employers’ liability coverage. Tim Lee Templeman nancytempleman@gmail.com self Atlantic Iowa Iowa Tara Jessen Alfred Wede 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
759 2021-11-19 18:54 Anonymous (not verified) 173.23.148.83 EFP Construction Limited Liability Company 1825 East Grand Ave Des Moines, Iowa 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-19 Bobby Perry efpconstruction21@gmail.com Des Moines Polk Iowa Tanya Perry Megan McIlhon Signed (1) The employer does not elect the employers’ liability coverage. Bobby Perry efpconstruction21@gmail.com Self Des Moines Polk Iowa Tanya Perry Megan McIlhon Signed
1114 2022-05-17 15:30 Anonymous (not verified) 67.212.117.198 Busta Painting Limited Liability Company 610 W 26th st #1 Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-16 Evan Busta bustapainting@gmail.com Cedar Falls IA United States Tanner Heikens Garrett Burrack Signed (1) The employer does not elect the employers’ liability coverage. Evan Busta bustapainting@gmail.com Self Employeed Cedar Falls IA United States Tanner Heikens Garrett Burrack Signed
1090 2022-05-06 08:08 Anonymous (not verified) 65.111.39.23 Farr TRucking Inc Proprietorship 2206 E Locust Ln, Table Grove, IL 61482 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Donald Paul Farr howthewestisdone@gmail.com Table Grove Fulton Illinois Tamra Stambaugh Keith Allard Signed (1) The employer does not elect the employers’ liability coverage. DeYonne L Farr howthewestisdone@gmail.com Secretary Table Grove Fulton Illinois Tamra Stambaugh Keith Allard Signed
83 2020-02-28 12:55 Anonymous (not verified) 204.16.58.27 Baltes Trucking LLC Limited Liability Company 203 N Gilmore Ave New Hampton IA 50659 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-28 Clinton Lee Baltes clintbaltes@gmail.com New Hampton Chickasaw Iowa Tammy Robinson Richard Kramer Signed (1) The employer does not elect the employers’ liability coverage. Clinton Lee Baltes clintbaltes@outlook.com Owner New Hampton Chickasaw Iowa Tammy Robinson Richard Kramer Signed
1411 2023-01-06 12:35 Anonymous (not verified) 72.255.93.91 Amayas Painting Proprietorship 1501 Mattern Ave, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-01 Carlos Alexando Amaya Garcia bmoellers@thebookkeepersinc.net Des moines Polk IA Tammy Robbins Gary Cort Signed (1) The employer does not elect the employers’ liability coverage. Brett Moelles bmoellers@thebookkeepersinc.net Accountant Des Moines Polk IA Tammy Robbins Gary Cort Signed
108 2020-04-01 16:50 Anonymous (not verified) 206.72.23.71 Heartland Renovations, LLC Limited Liability Company 50253 290th Street, Kelley, IA 50134 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-01 Troy Van Maaren almostanything2@gmail.com Kelley Iowa United States Tammy J Reid Todd L Greenslit Signed (1) The employer does not elect the employers’ liability coverage. Troy Van Maaren almostanything2@gmail.com Member Kelley Story Iowa Tammy J Reid Todd L Greenslit 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
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
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
169 2020-05-28 11:31 Anonymous (not verified) 173.31.147.225 RECYCLED SPIRITS LLC Limited Liability Company 43 ANN ST MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-28 BETH LAMB BLAMB@SPENCERSCHOOLS.ORG MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. BETH LAMB BLAMB@SPENCERSCHOOLS.ORG SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
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
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
344 2020-12-28 11:31 Anonymous (not verified) 173.31.147.225 JEFFREY GOETZINGER Proprietorship 2112 ITHACA AVE SPIRIT LAKE IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-22 JEFFREY GOETZINGER WALKERINSURANCE@MCHSI.COM SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JEFFREY GOETZINGER WALKERINSURANCE@MCHSI.COM SELF SPIRIT LAKE DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
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
416 2021-03-02 10:33 Anonymous (not verified) 173.31.147.225 TJ NAIG DBA NAIG CONSULTING Proprietorship PO BOX 678 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. 2021-02-25 TJADEN NAIG TJADENNAIG@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JOE LORING Signed (1) The employer does not elect the employers’ liability coverage. TJADEN NAIG TJADENNAIG@GMAIL.COM SELF ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JOE LORING Signed
600 2021-08-12 11:04 Anonymous (not verified) 173.19.179.111 ELIJAH HIX Proprietorship PO BOX 465 MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-11 ELIJAH HIX HIXSKIDOO800@GMAIL.COM MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ELIJAH HIX HIXSKIDOO800@GMAIL.COM SELF MILFORD DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
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
790 2021-12-14 10:59 Anonymous (not verified) 173.31.148.43 SILVER LAKE ACCOUNTING LLC Limited Liability Company 178 W BAY RD I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-13 DARYA GAY DGAY@SILVERLAKEACCOUNTING.CPA LAKE PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. DARYA GAY DGAY@SILVERLAKEACCOUNTING.CPA SELF LAKE PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
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
1309 2022-09-15 09:58 Anonymous (not verified) 96.31.1.206 PATTONS POWDER COATING Limited Liability Company 421 W MAPLE DRIVE HARTLEY IA 51346 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-15 DAVID PATTON PATTONSPOWDERCOATING@GMAIL.COM HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. PATTONS POWDER COATING - DAVID PATTON PATTONSPOWDERCOATING@GMAIL.COM SELF HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed
1382 2022-12-07 14:40 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC Limited Liability Company PO BOX 317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-25 AARON JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. AARON JONES STAYBOJI@GMAIL.COM SELF ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
1383 2022-12-07 14:42 Anonymous (not verified) 96.31.1.206 IGL RENTAL LLC Limited Liability Company PO BOX 317 ARNOLDS PARK IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-25 CHAD JONES STAYBOJI@GMAIL.COM ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. CHAD JONES STAYBOJI@GMAIL.COM SELF ARNOLDS PARK DICKINSON IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
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
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
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
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
2060 2024-02-28 09:36 Anonymous (not verified) 94.188.207.228 BRANDON LEHNER Proprietorship 308 SANFORD STREET ARCHER IA 51231 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-28 BRANDON LEHNER BLEHNER302@GMAIL.COM ARCHER OBRIEN IA TAMI KLEIN JOSEPH LORING Signed (1) The employer does not elect the employers’ liability coverage. BRANDON LEHNER BLEHNER302@GMAIL.COM SELF ARCHER OBRIEN IA TAMI KLEIN JOSEPH LORING Signed
749 2021-11-15 16:05 Anonymous (not verified) 173.31.148.43 CHAMONE SWITZER Proprietorship PO BOX 72 FOSTORIA IA 51340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-15 CHAMONE SWITZER CHAMONE.SWITZER@GMAIL.COM FOSTORIA DICKINSON IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed (1) The employer does not elect the employers’ liability coverage. CHAMONE SWITZER CHAMONE.SWITZER@GMAIL.COM SELF FOSTORIA IA United States TAMI KILEIN JENNIFER YOUNGWIRTH Signed
1808 2023-08-17 17:17 Anonymous (not verified) 94.188.205.168 Treimer Trucking LLC Limited Liability Company 3277 102nd St. Durant, IA 52747-9524 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-17 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Iowa United States Sydney Rae Lane Spencer Lea Parsons Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Self Tipton Iowa United States Syndey Rae Lane Spencer Lea Parsons Signed
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
1188 2022-07-07 11:24 Anonymous (not verified) 107.117.176.70 Pitts Aerial Services LLC Limited Liability Company 2478 county road 1488 Cullman al 35058 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Austin Branch Pitts pittsaerial@gmail.com Cullman Cullman AL Sydney Pitts James Robertson Signed (1) The employer does not elect the employers’ liability coverage. Austin Branch Pitts pittsaerial@gmail.com Owner Cullman Cullman AL Sydney Pitts James Robertson Signed
1189 2022-07-07 11:50 Anonymous (not verified) 71.91.55.59 Austin Branch Pitts Proprietorship 2478 county road 1488 Cullman al 35058 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Austin Branch Pitts pittsaerial@gmail.com Cullman Cullman AL Sydney Pitts James Robertson Signed (1) The employer does not elect the employers’ liability coverage. Austin Branch Pitts pittsaerial@gmail.com Proprietor Cullman Cullman AL Sydney Pitts James Robertson Signed
2111 2024-03-21 14:28 Anonymous (not verified) 94.188.205.168 James Watson Limited Liability Company 4708 71st Street Urbandale, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-24 James Edward watson junior99@email.com Urbandale IA United States Susie Givant Doug Frame Signed (1) The employer does not elect the employers’ liability coverage. Jason Lantz jason@lantzelite.com Employer Urbandale IA United States Susie Givant Doug Frame Signed
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
1714 2023-06-27 09:14 Anonymous (not verified) 94.188.205.167 Meier Trucking LLC Limited Liability Company 35032 308th St, Bellevue, IA 52031 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-14 Brandon Meier meierturcking87@yahoo.com Bellevue Jackson Iowa Susan Miller Nicole Mensen Signed (1) The employer does not elect the employers’ liability coverage. Brandon Meier meiertrucking87@yahoo.com self Bellevue Jackson Iowa Susan Miller Nicole Mensen Signed
1816 2023-08-23 14:59 Anonymous (not verified) 94.188.207.227 CHRIS PIERCE CONSTRUCTION LLC Proprietorship 500 N 8th StAkron, IA 5100 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-23 Chris Pierce chrispierceconstructionllc@gmail.com Akron Plymouth IA Susan Geist Paychex Insurance Agency Signed (1) The employer does not elect the employers’ liability coverage. Susan Geist sgeist@paychex.com Insurance Agency Rochester Monroe NY Susan Geist Paychex Insurance Agency Signed
1731 2023-07-10 11:12 Anonymous (not verified) 94.188.207.228 Romer & Associates LLC Limited Liability Company 433 Thomas Avenue, Maquoketa, IA 52060 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-10 Clay K Romer connellsupply@aol.com Maquoketa Jackson IA Susan Croatt Dave Stockham Signed (1) The employer does not elect the employers’ liability coverage. Clay K Romer connellsupply@aol.com Owner/same Maquoketa Jackson IA Susan Croatt Dave Stockham Signed
1956 2023-12-14 13:45 Anonymous (not verified) 94.188.207.226 Fey Concrete Inc Proprietorship 307 East Judson St, Maquoketa, IA 52060 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-14 Charles W Fey chuckfey55@gmail.com Maquoketa Jackson Iowa Susan Croatt Dave Stockham Signed (1) The employer does not elect the employers’ liability coverage. Charles W Fey chuckfey55@gmail.com Owner/same Maquoketa Jackson Iowa Susan Croatt Dave Stockham Signed
1408 2023-01-04 16:12 Anonymous (not verified) 50.82.188.217 Guerrero Masonry Proprietorship 5003 Keystone Rdg SE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Jaime Guerrero jaime.guerrero@mchsi.com Cedar Rapids IA United States Susan Bender Larry Bender Signed (1) The employer does not elect the employers’ liability coverage. Jaime Guerrero jaime.guerrero@mchsi.com self CEDAR RAPIDS Linn Iowa Susan Bender Larry Bender Signed
1976 2024-01-04 15:48 Anonymous (not verified) 94.188.207.224 Brawdy Services Proprietorship 7029 Prairie Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-01 Victor Brawdy heather.l.brawdy@gmail.com Urbandale Polk IA Summer Munoz Jennifer Wolters Signed (1) The employer does not elect the employers’ liability coverage. Victor Brawdy vb69ia@gmail.com Self Urbandale Polk IA Summer Munox Jennifer Wolters Signed
57 2020-02-10 15:33 Anonymous (not verified) 198.167.182.164 AllEnhancements LLC Limited Liability Company 1122 Woodland Ln, LeClaire, IA 52753 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-31 Brett Allen allenhancementsllc@outlook.com LeClaire Scott Iowa Steven J Fishman E Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Brett Allen allenhancementsllc@outlook.com Managing Member LeClaire Scott Iowa Steven J Fishman E Dyan Kriener Signed
59 2020-02-11 11:34 Anonymous (not verified) 198.167.182.164 Besch Electric LLC Limited Liability Company 317 Sycamore St, Riverside, IA 52327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-03 Daniel Besch beschd@hotmail.com Riverside Washington Iowa Steven J Fishman E Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Daniel Besch beschd@hotmail.com Managing Member Riverside Washington Iowa Steven J Fishman E Dyan Kriener Signed
60 2020-02-12 10:10 Anonymous (not verified) 198.167.182.164 Sara Torres Proprietorship 419 Lilac St, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-11 Sara Torres skb_blue08@hotmail.com Tiffin Johnson Iowa Steven J Fishman E. Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Sara Torres skb_blue08@hotmail.com Owner Tiffin Johnson Iowa Steven J Fishman E Dyan Kriener Signed
485 2021-04-16 11:58 Anonymous (not verified) 69.57.23.123 CRAIG AUKES Proprietorship 43397 50TH AVENUE, BUFFALO CENTER, IA 50424 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-16 CRAIG AUKES cdaukes@yahoo.com Buffalo Center Winnebago Iowa Steven Heyer Cindy Mawdsley Signed (1) The employer does not elect the employers’ liability coverage. CRAIG AUKES cdaukes@yahoo.com Employer-Proprietor Buffalo Center Winnebago IA Steven Heyer Cindy Mawdsley Signed
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
1821 2023-08-29 10:11 Anonymous (not verified) 94.188.205.169 Des Moines Smart Solutions LLC Limited Liability Company 1329 56th St., Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-29 Denzel Colocho alejandro_colocho@yahoo.com Des Moines Polk Iowa Steve Webb Austin Kelderman Signed (1) The employer does not elect the employers’ liability coverage. Des Moines Smart Solutions LLC alejandro_colocho@yahoo.com Owner Des Moines Polk Iowa Steve Webb Austin Kelderman Signed
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
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
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
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
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
438 2021-03-17 06:52 Anonymous (not verified) 198.167.182.164 David L Ridnour Proprietorship 1415 4th St, Perry, IA 50220 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-16 David L Ridnour dlridnour@gmail.com Perry Dallas Iowa Steve Fishman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. David L Ridnour dlridnour@gmail.com Owner Perry Dallas Iowa Steve Fishman Dyan Kriener Signed
505 2021-05-10 07:06 Anonymous (not verified) 69.63.16.2 Three Boys Contracting LLC Limited Liability Company 1108 Cullen Dr, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-08 Brandon J Campbell threeboyscarpentry@gmail.com Tiffin Johnson Iowa Steve Fishman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Brandon J Campbell threeboyscarpentry@gmail.com Managing Member Tiffin Johnson Iowa Steve Fishman Dyan Kriener Signed
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
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
1465 2023-02-17 15:05 Anonymous (not verified) 94.188.207.228 Big roofing Proprietorship 114 sw 58th dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 David Christiansen Mattc@bigroofing515.com Des moines Polk IA STEVE BIEGHLER Jordan walkup Signed (1) The employer does not elect the employers’ liability coverage. Matt christiansen Mattc@bigroofing515.com Self Des moines County Ia Steve bieghler Jordan walkup Signed
1468 2023-02-17 16:17 Anonymous (not verified) 94.188.207.230 AJ Cook LLC Limited Liability Company 1817 Redbud Street, Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 Alejandro Cook alejandro.cook14@gmail.com Norwalk Warren Iowa Steve Bieghler Nichole Bishop Signed (1) The employer does not elect the employers’ liability coverage. Alejandro Cook alejandro.cook14@gmail.com Self Norwalk Warren Iowa Steve Bieghler Nichole Bishop Signed
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
546 2021-06-22 15:41 Anonymous (not verified) 208.95.1.97 BAJ FLOORING, LLC Limited Liability Company 31533 CASTLE COURT, DYERSVILLE, IA. 52040 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-06-11 BRIAN JACQUE jacquebrian18@gmail.com DYERSVIILLE DUBUQUE IOWA STEPHEN J. SCHLUETER PAULA FITZGERALD Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. BRIAN JACQUE jacquebrian18@gmail.com LLC MEMBER DYSERSVILLE DUBUQUE IOWA STEPHEN J. SCHLUETER PAULA FITZGERALD Signed
633 2021-09-08 10:35 Anonymous (not verified) 208.95.1.97 BAJ Flooring, LLC Limited Liability Company 31533 Castle Ct. Dyersville, IA. 52040-7600 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-09-08 Brian Jacque JacqueBrian18@gmail.com Dyersville Dubuque Iowa Stephen J. Schluter Paula Fitzgerald Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Brian A. Jacque JacqueBrian18@gmail.com LLC MEMBER Dyersville DUBUQUE IOWA Stephen J. Schlueter Stephen J. Schlueter Signed
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
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
1578 2023-04-17 15:33 Anonymous (not verified) 94.188.205.174 Spark Train Express LLC Limited Liability Company 16877 500th St, Pocahontas, IA 50574 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-17 Austin Sparks sparksaustin.11@gmail.com Pocahontas Pocahontas Iowa Stephanie Webbink Christian Lynch Signed (1) The employer does not elect the employers’ liability coverage. Austin Sparks sparksaustin.11@gmail.com Owner Pocahontas Pocahontas Iowa Stephanie Webbink Christian Lynch Signed
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
1364 2022-11-09 09:57 Anonymous (not verified) 50.80.120.38 Egl Enterprises, Inc. Proprietorship 314 2ND AVE NW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-09 EUGENE G LARUE egl.enterprises.inc@gmail.com HAMPTON IA United States stephanie hofer aryel laRue Signed (1) The employer does not elect the employers’ liability coverage. EUGENE G LARUE egl.enterprises.inc@gmail.com self HAMPTON IA United States stephanie hofer aryel laRue Signed
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
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
1223 2022-07-22 15:14 Anonymous (not verified) 167.142.255.81 HomeOwner's Helper LLC Limited Liability Company 111 4th Ave, Underwood, IA 51576 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-22 Bradley W Syndergaard mrslouie8@yahoo.com UNDERWOOD Iowa United States Stacy L Louison Brent C Louison Signed (1) The employer does not elect the employers’ liability coverage. Bradley W Syndergaard mrslouie8@yahoo.com Self UNDERWOOD Iowa United States Stacy L Louison Brent C Louison Signed
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
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
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
1803 2023-08-15 19:03 Anonymous (not verified) 94.188.207.224 Teimer Trucking LLC Limited Liability Company 3277 102nd St. Durant, IA 52747-9524 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-15 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Iowa United States Spencer Lea Parsons Sydney Rae Lane Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Self Tipton Iowa United States Spencer Lea Parsons Sydney Rae Lane Signed
585 2021-07-25 20:07 Anonymous (not verified) 75.162.247.154 CJNR Works, LLC Limited Liability Company 17003 Bowdin Crest Drive, Cypress, Texas 77433 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-25 Christopher Ridgway christopherridgway@gmail.com Cypress Harris TX Sophia Ridgway Mitchel Monahan Signed (1) The employer does not elect the employers’ liability coverage. Christopher Ridgway christopherridgway@gmail.com Self Cypress Harris TX Sophia Ridgway Mitchel Monahan Signed
625 2021-08-30 20:39 Anonymous (not verified) 173.16.140.101 Phthalo Consulting LLC Limited Liability Company 2917 47th St, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-30 Angela Stone-Wiegert angela@phthaloconsulting.com Des Moines Polk Iowa Sonya Shippy Kenny Shippy Signed (1) The employer does not elect the employers’ liability coverage. Angela Stone-Wiegert angela@phthaloconsulting.com Owner Des Moines Polk Iowa Sonya Shippy Kenny Shippy Signed
1793 2023-08-09 15:23 Anonymous (not verified) 94.188.205.174 Cesar estuardo marroquin gonzalez Proprietorship 1212 David st waterloo iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-09 Cesar estuardo marroquin gonzalez marroquincesar1788@gmail.com 1212 David st waterloo iowa Black haw Iowa Sonia Gomez Sonia Gomez Signed (1) The employer does not elect the employers’ liability coverage. Cesar estuardo marroquin gonzalez marroquincesar1788@gmail.com Patrón 1212 David st waterloo iowa Black hawn Iowa Sonia Gomez Sonia Gomez Signed
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
1653 2023-05-18 09:45 Anonymous (not verified) 94.188.205.166 Darwin Gonzales Rodriguez Proprietorship 511 5th Street NE Belmond IA 50421 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-10 Darwin Gonzales Rodriguez office.seamlesspros@icloud.com Belmond Wright Iowa Soila Perez Keith Clabaugh Signed (1) The employer does not elect the employers’ liability coverage. Darwin Gonzales Rodriguez office.seamlesspros@icloud.com Self Belmond Wright Iowa Soila Perez Keith Clabaugh Signed
1424 2023-01-17 17:34 Anonymous (not verified) 173.191.246.189 Jabe Ramsey Proprietorship 216 South Park Street Osceola, IA 50213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-17 Jabe Hatfield Ramsey jaberamsey@icloud.com Osceola IA United States Sofia Contreras Katie Anne Carson Signed (1) The employer does not elect the employers’ liability coverage. Jabe Ramsey jaberamsey@icloud.com ME Osceola Clarke IOWA Sofia Contreras Katie Anne Carson Signed
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
492 2021-04-22 08:33 Anonymous (not verified) 66.188.136.150 Adrian Hackney Proprietorship 1513 7th St. Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-20 Adrian Hackney kschumacher@tricorinsurance.com Boone Boone IA Shuree Behr Mitch Kemp Signed (1) The employer does not elect the employers’ liability coverage. Adrian Hackney kschumacher@tricorinsurance.com Same Boone Boone IA Shuree Behr Mitch Kemp Signed
493 2021-04-22 08:54 Anonymous (not verified) 66.188.136.150 Frank Lantz Proprietorship 609 Clinton Street, Charles City, IA 50616 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-21 Frank Lentz kschumacher@tricorinsurance.com Charles City Floyd IA Shuree Behr Mitch Kemp Signed (1) The employer does not elect the employers’ liability coverage. Frank Lantz kschumacher@tricorinsurance.com Same Charles City Floyd IA Shuree Behr Mitch Kemp Signed
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
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
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
1332 2022-10-12 20:44 Anonymous (not verified) 209.252.174.114 Nelson Tile Proprietorship 300 Shetland Dr. N.W. Cedar Rapids, Ia. 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-12 Bruce Allen Nelson sherylnelson15@yahoo.com Cedar Rapids Linn Iowa Sheryl Marie Nelson Roger Eugene Nelson Signed (1) The employer does not elect the employers’ liability coverage. Bruce Allen Nelson sherylnelson@yahoo.com Owner,operator / same Cedar Rapids Linn Iowa Sheryl Marie Nelson Roger Eugene Nelson Signed
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
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
174 2020-06-05 15:10 Anonymous (not verified) 98.21.202.208 Bloomfield Properties LLC Limited Liability Company 206 Weaver Road, Bloomfield, IA 52537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-05 Terri Roberts terri_roberts58@yahoo.com Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed (1) The employer does not elect the employers’ liability coverage. Terri Roberts terri_roberts58@yahoo.com shareholder Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed
175 2020-06-05 15:14 Anonymous (not verified) 98.21.202.208 Bloomfield Properties LLC Limited Liability Company 206 Weaver Road, Bloomfield, IA 52537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-05 Dave Lawrence terri_roberts58@yahoo.com Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed (1) The employer does not elect the employers’ liability coverage. Terri Roberts terri_roberts58@yahoo.com shareholder Ottumwa Wapello Iowa Sheri Moore Cassidy Dimmitt Signed
2221 2024-05-13 09:26 Anonymous (not verified) 94.188.207.226 Chad matthews Proprietorship 3000 Justin dr. Suite J I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. 2024-05-13 Chad matthews kaceno2269@gmail.com Urbandale IA United States Sheri Frazier Terry warren Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Chad Matthews kaceno2269@gmail.com None Urbandale IA United States Sheri Fraiser Terry Warren Signed
908 2022-02-09 15:06 Anonymous (not verified) 63.152.66.183 Shear Texture Limited Liability Company 1427 A Ave NW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-09 Wendy Kiser kiser187@msn.com Cedar Rapids Linn Iowa Shelly Wehr Kimberly Erickson Signed (1) The employer does not elect the employers’ liability coverage. Wendy Kiser kiser187@msn.com Self Cedar Rapids Linn Iowa Shelly Wehr Kimberly Erickson 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
418 2021-03-03 13:50 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Abigail Jayne Glendenning lanceandabby@wccta.net Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Lance Jeffrey Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
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
420 2021-03-03 13:53 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 Terry Scott 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
1397 2022-12-21 14:05 Anonymous (not verified) 50.81.162.60 Jesse Iseminger Proprietorship 3117 e 40th ct, Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-21 Jesse Iseminger Jesseiseminger@gmail.com Des Moines Polk Iowa Shelly Johns Brad Weikert Signed (1) The employer does not elect the employers’ liability coverage. Jesse Iseminger Jesseiseminger@gmail.com Self Des Moines Iowa Iowa Shelly Johns Brad Weikert Signed
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
941 2022-03-02 09:06 Anonymous (not verified) 173.18.150.140 515 Trucking, L.L.C. Limited Liability Company 4613 E Valdez Dr, 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. 2022-03-02 Thomas L Garrett 515TruckHaul@gmail.com Des Moines Polk Iowa Shelley L Garrett Sheila J Wyman Signed (1) The employer does not elect the employers’ liability coverage. Thomas L Garrett 515TruckHaul@gmail.com Owner Des Moines Polk Iowa Shelley L Garrett Sheila J Wyman Signed
1683 2023-06-09 07:11 Anonymous (not verified) 94.188.207.226 Daves Boys Moving and Hauling LLC Limited Liability Company 264 Derbyshire Rd. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-09 Curtis Lane Curtis@davesboys.com Waterloo Blackhawk County IA Shelley Caughron Macray Caughron Signed (1) The employer does not elect the employers’ liability coverage. Curtis Lane Curtis@davesboys.com Myself Waterloo Blackhawk IA Shelley Caughron Macray Caughron Signed
1700 2023-06-22 14:53 Anonymous (not verified) 94.188.205.166 James Trotter Limited Liability Company 1341 Cachelin Dr Carter Lake IA 51510 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-22 James Trotter trotterwizard@gmail.com Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed (1) The employer does not elect the employers’ liability coverage. James Trotter trotterwizard@gmail.com Self Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed
1701 2023-06-22 15:03 Anonymous (not verified) 94.188.207.228 Midwest Teleworks Limited Liability Company 1341 Cachelin Dr Carter Lake IA 51510 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-22 James Trotter trotterwizard@gmail.com Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed (1) The employer does not elect the employers’ liability coverage. James Trotter trotterwizard@gmail.com Owner Carter Lake Pottawattamie IA Shelby Schultz Elora Trotter Signed
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
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
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
1606 2023-04-26 11:42 Anonymous (not verified) 94.188.205.166 Dean Petty Proprietorship 309 Locust Street De Soto I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Dean Robert Petty dean.r.petty@gmail.com De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Dean Robert Petty dean.r.petty@gmail.com Owner 309 Locust Street De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed
1607 2023-04-26 11:42 Anonymous (not verified) 94.188.205.166 Dean Petty Proprietorship 309 Locust Street De Soto I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Dean Robert Petty dean.r.petty@gmail.com De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Dean Robert Petty dean.r.petty@gmail.com Owner 309 Locust Street De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed
1608 2023-04-26 11:51 Anonymous (not verified) 94.188.205.167 Jesus Lozano Proprietorship 1334 E 16th st Des Moines Iowa 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-26 Jesus Lozano Jesuslozano0086@icloud.com Des Moines Polk Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Jesus Lozano Jesuslozano0086@icloud.com Owner Des Moines Polk Iowa Sheanah Wright Derek Mullins Signed
1609 2023-04-26 11:58 Anonymous (not verified) 94.188.205.168 edwin gonzalez Proprietorship 115 e ayers st osceola ia 50213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 edwin gonzalez lrestrada83@gmail.com osceola Clark ia Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. edwin gonzalez lrestrada83@gmail.com owner osceola clarke ia Sheanah Wright Derek Mullins Signed
1610 2023-04-26 12:03 Anonymous (not verified) 94.188.205.175 Thomas J Mullins Proprietorship 6569 Vista Dr. 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. 2023-04-26 Thomas J Mullins mullinsthomasj@gmail.com West Des Moines Dallas IA Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Thomas J Mullins mullinsthomasj@gmail.com Self West Des Moines Dallas IA Sheanah Wright Derek Mullins 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
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
586 2021-07-26 08:37 Anonymous (not verified) 71.7.62.131 Jeffrey Knoot Proprietorship 1251 Illinois Dr. Knoxville IA, 50138-8862 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-26 Jeffrey Jon Knoot opsisdental@gmail.com Knoxville Marion Iowa Sharon Kay Spriggs Lisa Michelle Dudley Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Jon Knoot opsisdental@gmail.com self Knoxville Marion Iowa Sharon Kay Spriggs Lisa Michelle Dudley Signed
994 2022-03-22 12:19 Anonymous (not verified) 75.162.125.176 performance painting llc Limited Liability Company 4905 nw 4th street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-22 thomas lilly TLilly816@aol.com ankeny IOWA United States Sharon kay Gaulke Charles Thomas Cater Signed (1) The employer does not elect the employers’ liability coverage. Performance Painting LLC TLilly816@aol.com owner ankeny IOWA United States Sharon Kay Gaulke Charles Thomas Cater 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
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
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
1445 2023-02-08 14:56 Anonymous (not verified) 94.188.207.225 Spencer Imaging Center, LLC Limited Liability Company 710 S. Grand Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-08 William Jay Muller mullerwilliam@hotmail.com Spencer Clay IA Shanna Marie Kooker Chad A Roemeling Signed (1) The employer does not elect the employers’ liability coverage. Alexander Pruitt apruitt@ncn.net Partner Spencer Clay IA Shanna Marie Kooker Chad A Roemeling Signed
1454 2023-02-14 09:34 Anonymous (not verified) 94.188.207.227 Spencer Imaging Center, LLC Limited Liability Company 710 S. Grand Ave., Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-14 Alexander Pruitt apruitt@ncn.net Spencer Clay IA Shanna Marie Kooker Chad Roemeling Signed (1) The employer does not elect the employers’ liability coverage. William Muller mullerwilliam@hotmail.com Co owner Spencer Clay IA Shanna Marie Kooker Chad Roemeling Signed
1247 2022-08-08 16:43 Anonymous (not verified) 72.13.27.236 Williams Hardwood Flooring LLC Limited Liability Company 10359 Deer Trail I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-05 Chad Everett Williams williamshardwood@aol.com Anamosa IA IA Shane Kies Dave Reitseger Signed (1) The employer does not elect the employers’ liability coverage. Chad Everett Williams williamshardwood@aol.com Owner Anamosa IA IA Shane Kies Dave Reitseger Signed
889 2022-02-03 14:52 Anonymous (not verified) 207.177.96.173 Stecker Rentals Inc. Limited Liability Company 1439 Kate Shelley Dr. Boone IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-03 Holly Stecker hollystecker6@gmail.com Boone Boone IA Shana Mallas Laura Hutchcroft Signed (1) The employer does not elect the employers’ liability coverage. Holly Stecker hollystecker6@gmail.com Owner Boone Boone IA Shana Mallas Laura Hutchcroft Signed
406 2021-02-18 10:41 Anonymous (not verified) 165.225.61.119 Romeo Painitng Proprietorship 7 Waverly Dr Rock Island, IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-18 Jay Romeo jay.romeo12@yahoo.com Rock Island Rock Island IL Seth Rowland Ryan Myers Signed (1) The employer does not elect the employers’ liability coverage. Jay Romeo jay.romeo12@yahoo.com Self Rock island Rock Island IL Seth Rowland Ryan Myers Signed
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
408 2021-02-18 10:51 Anonymous (not verified) 165.225.61.119 Brandon Anderson Painting Proprietorship 608 30th St Rock Island, IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-21 Brandon Anderson banderson792@gmail.com Rock Island Rock Island IL Seth Rowland Jay Romeo Signed (1) The employer does not elect the employers’ liability coverage. Brandon Anderson banderson792@gmail.com Self Rock Island Rock Island IL Seth Rowland Jay Romeo Signed
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
1154 2022-06-14 00:27 Anonymous (not verified) 174.213.144.227 Arben Bahtirovic Partnership 3060 South East Grimes Blvd, Suite 100-300 Grimes, Iowa 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-06-14 Arben Bahtirovic arben2002@gmail.com West Des Moines Polk IOWA Senida bahtirovic Mario mandic Signed (1) The employer does not elect the employers’ liability coverage. Arben Bahtirovic arben2002@gmail.com Contractor West Des Moines Polk IOWA Senida bahtirovic Marijo mandic Signed
667 2021-10-11 19:33 Anonymous (not verified) 104.166.240.24 FS Custom Flooring Limited Liability Company 5729 NW 92nd street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-11 Filip Sakanovic filip@fscustomflooring.com Johnston IA United States Senad Sakanovic Filip Sakanovic Signed (1) The employer does not elect the employers’ liability coverage. FS Tiling and Ceramics filip@fscustomflooring.com N/A Johnston IA United States Senad Sakanovic Filip Sakanovic Signed
871 2022-01-29 15:43 Anonymous (not verified) 173.31.116.134 West cleaning Proprietorship 8925 Cascade Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-29 Fata Omerovic fataomerovic@msn.com West Des Moines IA Iowa Semir Omerovic Samir Omerovic Signed (1) The employer does not elect the employers’ liability coverage. Fata Omerovic fataomerovic@msn.com Same person West Des Moines IA Iowa Semir Omerovic Samir Omerovic Signed
1539 2023-03-28 16:50 Anonymous (not verified) 94.188.207.230 Sulzner Construction LLC Limited Liability Company 210 N CHERRY ST, PO BOX 264 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-28 Aksel C Sulzner akselsmoke@gmail.com Mechanicsville IA United States self self Signed (1) The employer does not elect the employers’ liability coverage. Aksel C Sulzner akselsmoke@gmail.com Self Mechanicsville IA United States self self Signed
19 2019-12-31 16:29 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Amar Music amarmusic01@gmail.com Owner Urbandale IA United States Sefik Music Amara Crncevic Signed
20 2019-12-31 16:36 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Omer Okic ultimate.exteriors@gmail.com Owner Des Moines Polk IA Sefik Music Amara Crncevic Signed
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
90 2020-03-13 15:44 Anonymous (not verified) 173.24.190.134 Heath Householder Limited Liability Company 2 N Huron Street, Emmetsburg IA 50536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-07 Heath Householder heath679@live.com Emmetsburg Palo Alto Iowa Scott Wirtz Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Heath Householder heath679@live.com Member of LLC Emmetsburg Palo Alto Iowa Scott Wirtz Candie Clark Signed
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
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
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
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
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
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
151 2020-05-07 15:57 Anonymous (not verified) 198.167.182.164 Hawk-I Trucking LLC Limited Liability Company 521 Greenfield Dr, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-06 Chad Lee Freeman ricenogle@southslope.net Tiffin Johnson IA Scott Freeman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Chad Lee Freeman ricenogle@southslope.net Managing Member Tiffin Johnson IA Scott Freeman Dyan Kriener Signed
152 2020-05-11 15:56 Anonymous (not verified) 198.167.182.164 Hawk-I Trucking LLC Limited Liability Company 521 Greenfield Dr, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-11 Tyler Rogers tylerrogersinc@yahoo.com Iowa City Johnson Iowa Scott Freeman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Tyler Rogers tylerrogersinc@yahoo.com Member Iowa City Johnson Iowa Scott Freeman Dyan Kriener 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
699 2021-10-28 21:28 Anonymous (not verified) 75.162.104.116 Hild Construction, LLC Limited Liability Company 6439 NE 5th Ave, Pleasant Hill, IA 50327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-28 Jason Hild dirtsailor133@gmail.com Pleasant Hill Iowa United States Scott Dart Michael Kramer Signed (1) The employer does not elect the employers’ liability coverage. Jason Hild dirtsailor133@gmail.com Self Pleasant Hill Polk United States Scott Dart Michael Kramer Signed
1831 2023-09-08 11:50 Anonymous (not verified) 94.188.207.223 GFORCE Limited Liability Company 529 Anderson Street Jewell IA 50130 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-06 Colten Abram Griffin G6@q.com Ames Story Iowa Scott Andrew Griffin Hunter Austin Griffin Signed (1) The employer does not elect the employers’ liability coverage. Hunter Austin Griffin G6@q.com Partner Urbandale Polk Iowa Scott Andrew Griffin Colten Abram Griffin Signed
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
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
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
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
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
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
1282 2022-08-25 06:51 Anonymous (not verified) 63.240.136.241 River City Property Services LLC. Limited Liability Company 1936 9th Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-25 Brandon Smith RiverCityPropertyServices@outlook.com Camanche Iowa United States Sarah Smith MIke Burmahl Signed (1) The employer does not elect the employers’ liability coverage. Brandon Smith RiverCityPropertyServices@outlook.com Partner Camanche Iowa United States Sarah Smith MIke Burmahl Signed
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
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
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
540 2021-06-08 21:40 Anonymous (not verified) 50.83.39.243 Brightland Appraisal Group Limited Liability Company 1348 Rolling Glen Dr. Marion IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-08 Eric Lamp eric.lamp@brightlandappraisal.com Marion Linn Iowa Sarah Lamp Linda Lamp Signed (1) The employer does not elect the employers’ liability coverage. Eric Allen Lamp eric.lamp@brightlandappraisal.com Self Marion Linn Iowa Sarah Lamp Linda Lamp Signed
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
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
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
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
718 2021-11-05 13:41 Anonymous (not verified) 209.252.172.87 Wayne Hunt Proprietorship 405 E 4th St Tipton, Ia 52772 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-12 Wayne Hunt installation@bachmeiercarpetone.com Tipton Cedar Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Wayne Hunt installation@bachmeiercarpetone.com Self Tipton Cedar Iowa Sarah Coberley Heather Howell 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
722 2021-11-05 14:07 Anonymous (not verified) 209.252.172.87 Jeremiah Lunsford Proprietorship 624 Carroll Dr SE, Cedar Rapids, IA 52403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-10 Jeremiah Lundsford jjaylunsford@gmail.com Cedar Paids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Jeremiah Lunsford jjaylunsford@gmail.com Self Employed Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed
723 2021-11-05 14:13 Anonymous (not verified) 209.252.172.87 Will Lacina Northstar Hardwood Floors Proprietorship 1211 G St Amana, IA 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. 2020-05-16 Will Lacina northstarhardwoodfloor@gmail.com Amana Iowa Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. William Lacina northstarhardwoodfloor@gmail.com Self Employed Amana Iowa Iowa Sarah Coberley Heather Howell 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
725 2021-11-05 14:32 Anonymous (not verified) 174.198.66.202 Jay Schulte Proprietorship 7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-15 Jay Schulte schultejay@Hotmail.com Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Jay Schulte schultejay@hotmail.com Self Employed Cedar Rapids Linn Ia Sarah Coberley Heather Howell Signed
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
727 2021-11-05 14:46 Anonymous (not verified) 174.198.66.202 Bret Swift Swift Enterprises Proprietorship 2240 Coldstream Drive NE, Cedar Rapids, Ia 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-13 Brett Swidt swiftenterprises@me.com Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed (1) The employer does not elect the employers’ liability coverage. Bret Swift swiftenterprises@me.com Self Employed Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed
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
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
1098 2022-05-12 17:54 Anonymous (not verified) 199.66.15.123 Timothy W Robinson Proprietorship 302 N Kenwood blvd Indianola IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-12 Timothy William Robinson williamswork18@gmail.com Indianola Warren Iowa Sarah Anne Robinson Andrew Gilbert Barber Signed (1) The employer does not elect the employers’ liability coverage. Timothy William Robinson williamswork18@gmail.com Sole proprietor Indianola Warren Iowa Sarah Anne Robinson Andrew Gilbert Barber 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
1444 2023-02-07 14:57 Anonymous (not verified) 173.21.126.4 Rhino Roofing Limited Liability Company 2534 Garfield AVE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-07 Irwins Martinez rhinoroofingsiding21@gmail.com Des Moines Polk Iowa Sara Titus Justin Williams Signed (1) The employer does not elect the employers’ liability coverage. Irwin Martinez rhinoroofing21@gmail.com Self Des Moines Polk Iowa Sara Titus Justin Williams Signed
76 2020-02-24 15:05 Anonymous (not verified) 97.64.133.18 Sky Roofing Partnership 1332 Idaho St., Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-01 Angel Jurado Liberty21424@gmail.com des moines Polk Iowa Valerie Cramer David Murray Signed (1) The employer does not elect the employers’ liability coverage. Cramer Law PLC cramerlaw@halousa.com Attorney Polk Polk Iowa Sara Mc Ginnis David Murray Signed
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
472 2021-04-13 10:58 Anonymous (not verified) 65.103.82.36 Scrap And More Proprietorship 1303 W Linn St. Marshalltown, IA. 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. 2019-05-01 Travis Bachman na@yahoo.com marshalltown marshall IA sarah Tami Signed (1) The employer does not elect the employers’ liability coverage. Travis Bachman na@yahoo.com owner marshalltown marsahll IA sara tami 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
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
1485 2023-02-25 18:14 Anonymous (not verified) 94.188.205.177 J&V painting Limited Liability Company 4759 woodland AV #56 West Des moines IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-25 Jessika Romero jony.bel.vla@gmail.com West Des Moines Polk Ia Samir rahmanovic Samir rahmanovic Signed (1) The employer does not elect the employers’ liability coverage. Jessika Romero jony.bel.vla@gmail.com Self West Des Moines Polk IA Samir Rahmanovic SAMIR RAHMANOVIC Signed
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
2101 2024-03-18 09:21 Anonymous (not verified) 94.188.205.166 Jason Tindle Proprietorship 4103 1st St. Des Moines, Ia 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-18 Jason Tindle jtconstruction93@yahoo.com DES MOINES IOWA United States Zach Miller Nick Soma Signed (1) The employer does not elect the employers’ liability coverage. Jason Tindle jtconstruction93@yahoo.com Myself Same Same Same Same Same Signed
1964 2023-12-22 10:19 Anonymous (not verified) 94.188.207.224 Dale Pahl Proprietorship 711 N. 1St. B105 Eldridge IA 52748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-21 Dale Pahl Pada7910@gmail.com Eldridge Scott Iowa Samantha weston Rick mayerhofer Signed (1) The employer does not elect the employers’ liability coverage. Dale Pada7910@gmail.com Self Eldridge Scott IA Samantha weston Rick Mayerhofer Signed
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
258 2020-09-15 13:14 Anonymous (not verified) 50.83.182.140 Moyer Painting Proprietorship 934 Norwood Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-15 jerome Moyer moyer_painting@live.com Norwalk IA United States Sally Moyer Adam Adams Signed (1) The employer does not elect the employers’ liability coverage. jerome b moyer moyer_painting@live.com Self norwalk IA United States sally moyer Adam Adams Signed
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
533 2021-06-03 20:37 Anonymous (not verified) 75.162.171.128 KP Repair LLC Limited Liability Company 719 10th St. NE Mason City, Iowa. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-03 Alexander Wessels kprepair@outlook.com MASON CITY Cerro Gordo IA Sadie Lonning Dusty Howe Signed (1) The employer does not elect the employers’ liability coverage. Alexander Wessels kprepair@outlook.com Owner MASON CITY Cerro Gordo IA Sadie Lonning Dusty Howe Signed
664 2021-10-05 15:01 Anonymous (not verified) 174.242.226.8 New Face Renovations Limited Liability Company 3563 Richland Circle Van Meter, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-05 Darin Benjamin Davis newfacereno@gmail.com Van Meter Dallas Iowa Ryan Young Betsy Davis Signed (1) The employer does not elect the employers’ liability coverage. Renda Building megemo@commdatalink.com Installer Grimes Polk Iowa Ryan Young Betsy Davis Signed
1911 2023-11-15 20:39 Anonymous (not verified) 94.188.205.174 Bkauzie-LLC dba CR Painting Limited Liability Company 3051 104th St Suite A Urbandale IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-15 Brian Kauzlarich brian@crpaintingdsm.com Altoona Polk Iowa Ryan Thompson Rylie Thompson Signed (1) The employer does not elect the employers’ liability coverage. Brian Kauzlarich brian@crpaintingdsm.com owner/self Altoona Polk Iowa Ryan Thompson Rylie Thompson Signed
482 2021-04-14 21:21 Anonymous (not verified) 98.17.35.5 K3 Recycling LLC Limited Liability Company 14801 180th Ave, Milo, IA 50166 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-14 Charles Raymond Kappelman charliekappelman@yahoo.com MILO Warren United States Ryan Matthew Kappelman John Allen Bahr Signed (1) The employer does not elect the employers’ liability coverage. K3 Recycling LLC charliekappelman@yahoo.com Co-owner Milo Warren Iowa Ryan Matthew Kappelman John Allen Bahr Signed
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
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
1601 2023-04-25 14:38 Anonymous (not verified) 94.188.207.230 francisco garcia Proprietorship 388 lesley ln ne I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-25 franscisco garcia frasicohinojosa@gmail.com cedar rapids linn iowa Ryan Klein Karina Jacobson Signed (1) The employer does not elect the employers’ liability coverage. francisco garcia frasicohinojosa@gmail.com N/A cedar rapids linn iowa Ryan Klein Karina Jacobson Signed
1183 2022-07-06 13:43 Anonymous (not verified) 50.82.95.247 2DL Construction, LLC Limited Liability Company 1134 21st Street, Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-06 Diego Lopez calihernandez01@icloud.com Des Moines Polk Iowa Ryan Johnson Deanna Yersin Signed (1) The employer does not elect the employers’ liability coverage. Diego Lopez calihernandez01@icloud.com Self Des Moines Polk Iowa Ryan Johnson Deanna Yersin Signed
709 2021-11-04 12:38 Anonymous (not verified) 50.83.182.182 All Pro Painting LLC Limited Liability Company 5431 Gear Street Prole 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. 2020-11-04 Tory Webb (United Trades Group LLC) toryw@unitedtradesgroup.org Norwalk Warren Iowa Ryan Drabek Dustin Kohler Signed (1) The employer does not elect the employers’ liability coverage. Adam Adams adam@allpropaintingdsm.com Project Manager Prole Warren Iowa Ryan Drabek Dustin Kohler Signed
710 2021-11-04 12:57 Anonymous (not verified) 50.83.182.182 United Trades Group LLC Limited Liability Company 4813 Candlewick Drive 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. 2020-11-04 Tory Webb torywebbdmi@gmail.com Norwalk Polk Iowa Ryan Drabek Dustin Kohler Signed (1) The employer does not elect the employers’ liability coverage. Tory Webb toryw@unitedtradesgroup.org Owner, Management Norwalk Iowa United States Ryan Drabek Dustin Kohler Signed
733 2021-11-09 15:35 Anonymous (not verified) 50.83.182.182 United Trades Group LLC Limited Liability Company 4813 Candlewick Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-09 Dustin Kohler dustink@unitedtradesgroup.org Des Moines Polk Iowa Ryan Drabek Trevor Spidle Signed (1) The employer does not elect the employers’ liability coverage. Tory Webb torywebbdmi@gmail.com Owner, Management Norwalk Warren Iowa Ryan Drabek Trevor Spidle Signed
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
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
120 2020-04-14 14:58 Anonymous (not verified) 66.188.136.150 Donald Hesseling Proprietorship 3200 East Shaulis Rd., Waterloo, IA 50702 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-14 Donald Hesseling donkd0wgb@outlook.com Waterloo Blackhawk County IA Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Dan Oberfoell doberfoell@tricorinsurance.com Agent Waterloo Blackhawk County IA Russell Masartis Nancy Wortley Signed
130 2020-04-27 10:36 Anonymous (not verified) 66.188.136.150 David Roberts Proprietorship 2600 Butterfield, PO Box 3251 Dubuque, IA 52004 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-24 David Roberts buman6578@gmail.com Dubuque Dubuque IA Russell Masartis Angie Olds Signed (1) The employer does not elect the employers’ liability coverage. David Roberts kschumacher@tricorinsurance.com Owner Operator is Employer Dubuque Dubuque IA Russell Masartis Angie Olds Signed
131 2020-04-27 15:01 Anonymous (not verified) 66.188.136.150 Hashem Shawki Proprietorship 8906 Newton Ave. S I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-27 Hashem Shawki kschumacher@tricorinsurance.com Bloomington Hennepin MN Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Hasham Shawki kschumacher@tricorinsurance.com Same person Bloomington Hennepin MN Russell Masartis Nancy Wortley Signed
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
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
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
167 2020-05-27 11:51 Anonymous (not verified) 66.188.136.150 Dennis Heinlen Proprietorship 3415 Upland Rd. Lowellville, OH I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-26 Dennis Heinlen kschumacher@tricorinsurance.com Lowellville Mahoning OH Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Dennis Heinlen kschumacher@tricorinsurance.com Same Lowellville Mahoning OH Russell Masartis Nancy Wortley Signed
172 2020-06-02 15:56 Anonymous (not verified) 66.188.136.150 David Bull Proprietorship 221 N Aarlocker St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-02 David Bull kschumacher@tricorinsurance.com Mount Hope Grant WI Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. David Bull kschumacher@tricorinsurance.com Same Mount Hope Grant WI Russell Masartis Nancy Wortley Signed
186 2020-06-15 08:03 Anonymous (not verified) 66.188.136.150 Candace Dingler Proprietorship 280 Trimble Station Road I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-10 Candace Dingler kschumacher@tricorinsurance.com Hogansville Troup GA Russell Masartis Angie Ords Signed (1) The employer does not elect the employers’ liability coverage. Candace Dingler kschumacher@tricorinsurance.com Same Hogansville Troup GA Russell Masartis Angie Ords Signed
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
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
206 2020-07-16 08:18 Anonymous (not verified) 97.64.194.122 Tommy Messino Proprietorship 205 S Taylor St., Cherry, IL 61317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Tommy Messino kschumacher@tricorinsurance.com Cherry Bureau IL Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Tommy Messino kschumacher@tricorinsurance.com Same Cherry Bureau IL Russell Masartis Shuree Behr Signed
214 2020-07-22 14:31 Anonymous (not verified) 66.188.136.150 David Fuller Proprietorship 19 Riviera Lane, Omro, WI 54963 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-14 David Fuller kschumacher@tricorinsurance.com Omro Winnebago WI Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. David Fuller kschumacher@tricorinsurance.com Same Omro Winnebago WI Russell Masartis Nancy Wortley Signed
225 2020-08-05 14:31 Anonymous (not verified) 66.188.136.150 William Brickley Proprietorship 327 E Prairie St., Wataga, IL 61488 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-03 William Brickley kschumacher@tricorinsurance.com Watage Knox IL Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. William Brickley kschumacher@tricorinsurance.com Same Wataga Knox IL Russell Masartis Nancy Wortley 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
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
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
315 2020-11-13 10:48 Anonymous (not verified) 66.188.136.150 Jessie Spurlin Proprietorship 58977 Al Hwy 77, Talladega, AL 35160 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-11 Jessie Spurlin kschumacher@tricorinsurance.com Talladega Talladega AL Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Jessie Spurlin kschumacher@tricorinsurance.com Same Talledaga Talledaga AL Russell Masartis Nancy Wortley Signed
316 2020-11-13 11:46 Anonymous (not verified) 66.188.136.150 Canebreak & Warlander Trucking, LLC Limited Liability Company 1020 Avenue F, Fort Madison, IA 52627 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-13 Canebreak & Warlander Trucking LLC kschumacher@tricorinsurance.com Fort Madison Lee IA Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Canebreak & Warlander Trucking LLC kschumacher@tricorinsurance.com Same Fort Madison Lee IA Russell Masartis Nancy Wortley Signed
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
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
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
353 2021-01-11 14:38 Anonymous (not verified) 66.188.136.150 Igor Curguz Proprietorship 927 1/2 W Grand Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-11 Igor Curguz kschumacher@tricorinsurance.com Beloit Rock WI Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Igor Curguz kschumacher@tricorinsurance.com Same Beloit Rock WI Russell Masartis Nancy Wortley Signed
356 2021-01-11 19:39 Anonymous (not verified) 66.188.136.150 David Whitfield Proprietorship 3947 Cracker Cove Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-11 David Whitfield kschumacher@tricorinsurance.com Canal Winchester Fairfield OH Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. David Whitfield kschumacher@tricorinsurance.com Same Canal Winchester Fairfield OH Russell Masartis Nancy Wortley Signed
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
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
373 2021-01-25 09:06 Anonymous (not verified) 66.188.136.150 Daniel Kulberg Proprietorship PO Box 641, Renville, MN 56284 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-25 Daniel Kulberg kschumacher@tricorinsurance.com Renville Renville MN Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Daniel Kulberg kschumacher@tricorinsurance.com Same Reville Renville MN Russell Masartis Shuree Behr Signed
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
401 2021-02-15 14:50 Anonymous (not verified) 66.188.136.150 Jarrod Wernimont Proprietorship 24 Blackhawk Rd. Hanover, IL 61041 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-12 Jarrod Wernimont kschumacher@tricorinsurance.com Hanover Jo Daviess IL Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Jarrod Wernimont kschumacher@tricorinsurance.com Same Hanover Jo Daviess IL Russell Masartis Shuree Behr Signed
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
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
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
431 2021-03-10 14:41 Anonymous (not verified) 66.188.136.150 Brad Donovan Proprietorship 1105 N 5th. Springfield, IL 62702 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-10 Brad Donovan braddonovan40@gmail.com Springfield Sangamon IL Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Brad Donovan braddonovan40@gmail.com Same Springfield Sangamon IL Russell Masartis Shuree Behr Signed
440 2021-03-18 08:11 Anonymous (not verified) 66.188.136.150 Jeffrey Gardner Proprietorship 3020 W 1st St., Davenport, IA 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-17 Jeffrey Gardner kschumacher@tricorinsurance.com Davenport Polk IA Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Gardner kschumacher@tricorinsurance.com Same Davenport Polk IA Russell Masartis Shuree Behr Signed
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
455 2021-03-31 13:35 Anonymous (not verified) 66.188.136.150 Cody Pazicni Proprietorship 222 Lake Shore Dr. Simpsonville, KY 40067 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-29 Cody Pazicni kschumacher@tricorinsurance.com Simpsonville Shelby KY Russell Masartis Jordan Pape Signed (1) The employer does not elect the employers’ liability coverage. Cody Pazicni kschumacher@tricorinsurance.com Same Simpsonville Shelby KY Russell Masartis Jodan Pape Signed
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
459 2021-04-05 14:24 Anonymous (not verified) 66.188.136.150 Gerald Bosch Proprietorship 14359 County Rd. G62 Wapello, IA 52653 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-02 Gerald Bosch kschumacher@tricorinsurance.com Wapello Louisa IA Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Gerald Bosch kschumacher@tricorinsurance.com Same Wapello Louisa IA Russell Masartis Shuree Behr Signed
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
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
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
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
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
979 2022-03-15 13:48 Anonymous (not verified) 72.255.78.146 Custom Climates Partnership 3305 Highway 1 SW Ste 9A Iowa City IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Allen Nichols ranichols4@gmail.com CEDAR RAPIDS Iowa IA Rose Nichols Rose Nichols Signed (1) The employer does not elect the employers’ liability coverage. Allen Nichols ranichols4@gmail.com spouse CEDAR RAPIDS Iowa IA Rose Nichols Rose Nichols Signed
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
1619 2023-04-28 11:20 Anonymous (not verified) 94.188.207.224 Hunter Flying Service, LLC Limited Liability Company PO Box 215 Hunter, AR 72074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-28 Adam Towe hunterflying@att.net Hartselle Morgan Alabama Ronnie Skinner Karen Gifford Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Lynn Cary hunterflying@att.net Owner Hunter Woodruff Arkansas Ronnie Skinner Karen Gifford Signed
1531 2023-03-24 08:40 Anonymous (not verified) 94.188.207.228 Schneiter Insurance and Financial Solutions Limited Liability Company 900 E 3RD ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-01 Jackie Schneiter grlschneiter@gmail.com MONTICELLO IA United States Ronald Schneiter Reagan Schneiter Signed (1) The employer does not elect the employers’ liability coverage. Jacqueline Schneiter jackie@we78ins.com owner ANAMOSA JONES IOWA RONALD SCHNEITER REAGAN SCHNEITER Signed
1666 2023-05-28 15:57 Anonymous (not verified) 94.188.207.223 Projects Under Development LLC Limited Liability Company 2516 Hickory Grove Rd Davenport Iowa 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-29 James Stock jamese1053@gmail.com Davenport Scott Ia Ronald Lang Karen Walker Signed (1) The employer does not elect the employers’ liability coverage. James Stock jamese1053@gmail.com Owner Davenport Scott Ia Ronald Lang Karen Walker Signed
1668 2023-05-30 10:50 Anonymous (not verified) 94.188.207.230 Projects Under Development LLC Limited Liability Company 2516 Hickory Grove Rd Davenport Iowa 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-30 James Stock jamese1053@gmail.com Davenport Scott Iowa Ronald Lang Karen Stock Signed (1) The employer does not elect the employers’ liability coverage. James Stock jamese1053@gmail.com Owener Davenport Scott Iowa Ronald Lang Karen Walker Signed
1669 2023-05-30 11:05 Anonymous (not verified) 94.188.207.225 Projects Under Development LLC Limited Liability Company 2516 Hickory Grove Rd Davenport IA 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-30 James Stock jamese1053@gmail.com Davenport Scott Ia Ronald Lang Karen Walker Signed (1) The employer does not elect the employers’ liability coverage. James Stock jamese1053@gmail.com Owner Davenport Scott l Ia Ronald Lang Karen Walker Signed
374 2021-01-25 12:15 Anonymous (not verified) 174.213.149.27 Vaughn Peyton Proprietorship 3060 19th avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-25 Vaughn Peyton vaughnage173@hotmail.com Marion Iowa United States Ronald Bart Peyton Kristine Katherine Peyton Signed (1) The employer does not elect the employers’ liability coverage. Vaughn Peyton vaughnage173@hotmail.com Myself Marion Iowa United States Ronald Bart Peyton Kristine Katherine Peyton Signed
642 2021-09-17 11:09 Anonymous (not verified) 167.142.95.56 Preferred Properties of Iowa, Inc. Limited Liability Company 500 W. Temple St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-17 Daniel Zech dan.ppi@gmail.com Lenox Taylor Iowa Ron Travis Maury Moore Signed (1) The employer does not elect the employers’ liability coverage. Dan Zech dan.ppi@gmail.com Owner Lenox Taylor Iowa Ron Travis Maury Moore Signed
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
644 2021-09-17 11:20 Anonymous (not verified) 167.142.95.56 Preferred Properties of Iowa, Inc. Limited Liability Company 500 W. Temple St., Lenox, IA 50851 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-17 Brennan Kester mdpearson88@gmail.com Corning Taylor Iowa Ron Travis Maury Moore Signed (1) The employer does not elect the employers’ liability coverage. Dan Zech dan.ppi@gmail.com owner Lenox Taylor Iowa Ron Travis Maury Moore Signed
879 2022-01-31 14:26 Anonymous (not verified) 173.27.146.201 Premier Window Cleaning LLC Limited Liability Company 420 E GRANGER AVE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-31 Frank Viola premierofiowa@gmail.com DES MOINES IA United States Ron Reynolds Chris Greco Signed (1) The employer does not elect the employers’ liability coverage. Frank Viola premierofiowa@gmail.com my self DES MOINES IA United States Ron Reynolds Chris Greco Signed
1628 2023-05-09 08:00 Anonymous (not verified) 94.188.205.175 Servin Drywall Proprietorship 6311 Underwood Ave SW, Cedar Rapids, IA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-09 Arcel Servin arcelservin77@gmail.com Cedar Rapids Linn Iowa Rolandas Bitanas Kirk Strunk Signed (1) The employer does not elect the employers’ liability coverage. Arcel Servin arcelservin77@gmail.com Self Cedar Rapids Linn Iowa Rolandas Bitanas Kirk Strunk Signed
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
305 2020-11-02 08:40 Anonymous (not verified) 204.124.192.31 JPS Framing Proprietorship 102 WALL AVE - DES MOINES IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-02 JACKELYN SANCHEZ JPSFRAMING629@GMAIL.COM DES MOINES POLK IOWA ROGELIO SANCHEZ DOMINIQUE SANCHEZ Signed (1) The employer does not elect the employers’ liability coverage. JUAN SERRANO JPSFRAMING629@GMAIL.COM EMPLOYER DES MOINES POLK IOWA ROGELIO SANCHEZ DOMINIQUE SANCHEZ Signed
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
1204 2022-07-14 11:59 Anonymous (not verified) 107.1.252.41 International Drywall LLC. Limited Liability Company 108 N 4th 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. 2022-07-14 Victoria G Cervantes vic8.cervantes@gmail.com Marshalltown IA United States Rodrigo Rodriguez Juan Cervantes Signed (1) The employer does not elect the employers’ liability coverage. Victoria G Cervantes Vic8.cervantes@gmail.com Self Marshalltown IA United States Rodrigo Rodriguez Juan Cervantes Signed
2156 2024-04-16 17:00 Anonymous (not verified) 94.188.205.166 BONILLA STONE LLC Limited Liability Company 3201 COLUMBIA ST DES MOINES, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-16 JAIRO JAVIER BONILLA SERRANO jairobonilla509@gmail.com DES MOINES POLK IOWA ROCIO REYES JOSE HERNANDEZ Signed (1) The employer does not elect the employers’ liability coverage. JAIRO JAVIER BONILLA SERRANO jairobonilla509@gmail.com SAME DES MOINES POLK IOWA ROCIO REYES JOSE HERNANDEZ Signed
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
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
1767 2023-07-28 14:31 Anonymous (not verified) 94.188.207.229 Kleckner Backhoe Service Proprietorship 1302 S 1st St, 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. 2023-07-28 Tracy S Kleckner terridkleckner@hotmail.com Osage Mitchell Iowa Robin Tabbert Jeannie Lemke Signed (1) The employer does not elect the employers’ liability coverage. L R Falk Construction Co jeannie@lrfalk.com Dump Truck Hauler Osage Mitchell Iowa Robin Tabbert Jeannie Lemke 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
451 2021-03-25 17:00 Anonymous (not verified) 166.181.80.120 Rogers conc,. const, Partnership 220804 CO, RD, ANAMOSA IA, 52205 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-25 Alex olah aolah43@gmail.com Cedar Rapids Linn Iowa Robin marie kane Augie rodreguez Signed (1) The employer does not elect the employers’ liability coverage. Kevin johnson kevinecollins@libertymutual.com Ins , Agent Appleton Dane Wisconsin Robin marie kane Augie Rodriguez Signed
452 2021-03-26 07:30 Anonymous (not verified) 173.31.109.49 Rogers Concrete Construction Partnership 22802 County Rd E34 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-26 Alexander Olah aolah43@gmail.com Cedar Rapids Linn Iowa Robin Marie Kane Augies Rodrigez Signed (1) The employer does not elect the employers’ liability coverage. Kevin Johnson kevinjohnson@libertymutual.com Insurance Agent Appleton Outagamie Wisconsin Robin Marie Kane Augie Rodrigez Signed
135 2020-04-28 10:04 Anonymous (not verified) 74.84.101.138 W.A.D.E., Inc. DBA Decorah Cleaners Proprietorship 504 Heivly Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Darrin Walter chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed (1) The employer does not elect the employers’ liability coverage. Darrin Walter chelsea.whalen@upperiowains.com Owner Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed
136 2020-04-28 10:06 Anonymous (not verified) 74.84.101.138 W. A. D. E., Inc. DBA Decorah Cleaners Proprietorship 504 Heivly Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Wanda Walter chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed (1) The employer does not elect the employers’ liability coverage. Wanda Walter chelsea.whalen@upperiowains.com Owner Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed
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
142 2020-04-28 10:16 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. 2020-02-18 Timothy A Stoddard chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed (1) The employer does not elect the employers’ liability coverage. Timothy A Stoddard chelsea.whalen@upperiowains.com Treasurer Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed
217 2020-07-27 14:56 Anonymous (not verified) 72.2.163.232 Calvin Kroger Proprietorship 48232 292nd St. Hudson, SD 57034 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-27 Calvin Kroger calvinkroger@gmail.com Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed (1) The employer does not elect the employers’ liability coverage. Calvin Kroger calvinkroger@gmail.com proprietor Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed
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
697 2021-10-28 15:30 Anonymous (not verified) 208.126.114.236 bartman express Limited Liability Company 1976 240th st bennett iowa 52721 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-28 bartin joesph steines bartmanexpress@gmail.com bennett cedar iowa Robert theordore jarrett dana marie shipler Signed (1) The employer does not elect the employers’ liability coverage. bartin joesph steines bartmanexpress@gmail.com self bennett cedar iowa robert theordore jarrett dana marie shipler Signed
18 2019-12-31 13:36 Anonymous (not verified) 162.253.44.28 Wade Roth DBA Roth TV and Appliance Proprietorship 1004 12th St, Belle Plaine, IA 52208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2019-12-09 Wade Roth WADEROTH@NETINS.NET Belle PLaine Benton Iowa Robert Sydnes Robert Sydnes Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Wade Roth WADEROTH@NETINS.NET Self Belle Plaine Benton Iowa Robert Sydnes Kurt Feller Signed
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
1269 2022-08-18 16:17 Anonymous (not verified) 67.55.174.140 Roberts Compliance Services, LLC Limited Liability Company 405 Hilltop Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-18 Daniel Roberts dan@robertscompliance.com Stanton Montgomery IA Robert Schenck Pier Osweiler Signed (1) The employer does not elect the employers’ liability coverage. Daniel Roberts dan@robertscompliance.com self Stanton Montgomery IA Robert Schenck Pier Osweiler Signed
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
1416 2023-01-09 13:05 Anonymous (not verified) 67.55.184.55 Austin Lanz Proprietorship 3015 M Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-09 Austin Robert Lanz austinlanz52@gmail.com Moring Sun Iowa IA Robert Lowell Lanz Jessica Leann Ewart Signed (1) The employer does not elect the employers’ liability coverage. Austin Robert Lanz austinlanz52@gmail.com Self Moring Sun Iowa IA Robert Lowell Lanz Jessica Leann Lanz Signed
599 2021-08-09 22:57 Anonymous (not verified) 70.39.22.76 The Bartman Express LLC Limited Liability Company 1976 240th St. Bennett IA 52721 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-09 Barton Steines bartmanexpress@gmail.com Bennett Cedar Iowa Robert Jarrett Michael Sexton Signed (1) The employer does not elect the employers’ liability coverage. Barton Steines bartmanexpress@gmail.com Self Bennett Cedar Iowa Robert Jarrett Michael Sexton Signed
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
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
2033 2024-02-07 11:38 Anonymous (not verified) 94.188.205.168 JENKINS CONSTRUCTION Proprietorship 315 NORTH MAIN STREET, P.O. BOX 124, ODEBOLT, IA 51458 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 DENNIS CHARLES JENKINS dcjmjenkins@yahoo.com ODEBOLT SAC IOWA ROBERT EUGENE BELT JOHN CLARENCE OLERICH Signed (1) The employer does not elect the employers’ liability coverage. DENNIS CHARLES JENKINS dcjmjenkins@yahoo.com SELF ODEBOLT SAC IOWA ROBERT EUGENE BELT JOHN CLARENCE OLERICH Signed
2143 2024-04-09 13:05 Anonymous (not verified) 94.188.207.230 CO2 Refrigeration Systems (Iowa) 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-09 Zachary Heintz Laws zach.laws@co2refsystems.com Marshalltown Marshall Iowa Robert E Shomo Steven M Madsen Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Zachary Heintz Laws zach.laws@co2refsystems.com Self Marshalltown Marshall Iowa Robert E Shomo Steven M Madsen Signed
1479 2023-02-24 08:34 Anonymous (not verified) 94.188.207.229 Sedenka Excavating and Habitat Limited Liability Partnership 204 Meadowview Drive, Lisbon, IA 52253 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Trey Sedenka SedenkaEH@gmail.com Lisbon Cedar Iowa Robert Cummings Jayson Wallace Signed (1) The employer does not elect the employers’ liability coverage. Trey Sedenka SedenkaEH@gmail.com Owner Lisbon Cedar Iowa Robert Cummings Jayson Wallace Signed
321 2020-11-17 10:26 Anonymous (not verified) 173.18.16.129 Adam Quimby Proprietorship 2033 10th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-01 Adam Quimby adam.m.quimby@gmail.com Des Moines Polk Iowa Robert Coluzzi Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Adam Quimby adam.m.quimby@gmail.com Owner Des Moines Polk Iow Robert Coluzzi Kelly Coluzzi Signed
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
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
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
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
1527 2023-03-22 08:35 Anonymous (not verified) 94.188.205.167 Quad Cities Transport Inc Proprietorship 1106 46th ave Rock Island IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-21 Howard Rick Clark Davis hdenterprisesinc14@gmail.com East Moline Rock Island IL Patrick Watkins Ricky Oconner Signed (1) The employer does not elect the employers’ liability coverage. Howard Davis qctransportinc@gmail.com Owner East Moline Rock Island Illinois Ricky Oconner Patrick Watkins Signed
1559 2023-04-07 11:43 Anonymous (not verified) 94.188.205.177 Art Deco Tile and Stone Limited Liability Company 4615 94th Pl Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-07 Edin Musinovic edin@artdecotileandstone.com Urbandale Polk Iowa Rick Wyant Todd Wyant Signed (1) The employer does not elect the employers’ liability coverage. Edin Musinovic edin@artdecotileandstone.com Self Urbandale Polk Iowa Rick Wyant Todd Wyant Signed
1560 2023-04-07 11:47 Anonymous (not verified) 94.188.205.174 Art Deco Tile and Stone Limited Liability Company 4615 94th Pl Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-07 Jasmin Musinovic edin@artdecotileandstone.com Urbandale Polk Iowa Rick Wyant Todd Wyant Signed (1) The employer does not elect the employers’ liability coverage. Jasmin Musinovic edin@artdecotileandstone.com Self Urbandale Polk Iowa Rick Wyant Todd Wyant Signed
2038 2024-02-08 07:44 Anonymous (not verified) 94.188.205.167 Travis Toney Limited Liability Company 932 w12th street south 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. 2024-02-08 Travis Duane Toney travistoney1984@gmail.com Newton United States IA Rick lee Toney Brenda Ann Toney Signed (1) The employer does not elect the employers’ liability coverage. Phil glazer kg_Info@capitallandscaping.com Contractor Des Moines United States IA Rick lee Toney Brenda Ann Toney Signed
336 2020-12-11 11:55 Anonymous (not verified) 173.16.197.72 A Metro Snow Removal And Lawn Care Limited Liability Company 6436 Washington Ave Windsor Heights, Iowa 50324 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-11 Jeff Lamp Sr. jeff.lamp79@gmail.com Windsor Height Polk Iowa Rick Brown Jill Fresh Signed (1) The employer does not elect the employers’ liability coverage. Jeff Lamp Sr. Jeff.lamp79@gmail.com Owner Windsor Heights Polk Iowa Rick Brown Jill Fresh Signed
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
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
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
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
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
249 2020-08-28 13:06 Anonymous (not verified) 97.125.184.147 Supernova Construction LLC Proprietorship 4665 171st St, Urbandale, IA 50323 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-28 Heraclio A Ayala heraclio.ayala@yahoo.com Urbandale Dallas IA Ricardo Alverio Valentin Garcia Signed (1) The employer does not elect the employers’ liability coverage. Heraclio Ayala heraclio.ayala@yahoo.com Sole Member Urbandale Dallas IA Ricardo Alverio Valentin Garcia Signed
2162 2024-04-18 19:25 Anonymous (not verified) 94.188.205.177 Escobar Enterprises, LLC Limited Liability Company 125 East Broad Street, Des Moines, Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-18 Jesse Escobar jesse@escobar-enterprises.com Des Moines Polk Iowa Rene Mauricio Martinez Jessa Caitlin Marfal Signed (1) The employer does not elect the employers’ liability coverage. Jesse Escobar jesse@escobar-enterprises.com owner Des Moines Polk Iowa Rene Mauricio Martinez Jessa Caitlin Marfal Signed
1496 2023-03-06 11:24 Anonymous (not verified) 94.188.207.227 Carrillo Drywall, LLC Limited Liability Company 119 Marsh St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-06 Yesenia Carrillo yesecarrillo84@gmail.com Waterloo IA United States Rene Carrillo Jr Martha Basurto Signed (1) The employer does not elect the employers’ liability coverage. Kyle Hildman kyleh@sinnottagency.com Insurance Agent Waterloo IA United States Rene Carrillo Jr Martha Basurto Signed
1497 2023-03-07 07:37 Anonymous (not verified) 94.188.207.229 Holzworth Land Company Limited Liability Company 1730 All State Ct Suite 100 West Des Moines, IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-03-07 Victor Holzworth holzconstruction@gmail.com West Des Moines Polk Iowa Reid Tamisiea Mariah Burgett Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Victor Holzworth holzconstruction@gmail.com Owner West Des Moines Polk iowa Reid Tamisea Mariah Burgett Signed
1250 2022-08-10 09:10 Anonymous (not verified) 75.162.190.54 Merit Paint Company Proprietorship 1629 24th St, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-10 James Edward Simpson jaybirdsimpson40@aol.com Des Moines Polk Iowa Regan Simpson Hudson Simpson Signed (1) The employer does not elect the employers’ liability coverage. James Simpson jaybirdsimpson40@aol.com Owner Des Moines Polk Iowa Regan Simpson Hudson Simpson Signed
2086 2024-03-08 19:11 Anonymous (not verified) 94.188.207.223 Handyman & More Limited Liability Company 1214 Lindwood Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-08 Dustin allen Bergman dustinbergman86@gmail.com Carter Lake IA United States Reesa Edie Douglas Scadin Signed (1) The employer does not elect the employers’ liability coverage. Dustin allen Bergman dustinbergman86@gmail.com Owner of company Carter Lake IA United States Reesa Edie Douglas Scadin Signed
866 2022-01-27 19:15 Anonymous (not verified) 199.66.15.25 Greg Cheno Services LLC Limited Liability Company 203 N H St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-27 Gregory Chenoweth gregcheno@gmail.com Indianola IA United States Rebecca Sue Abbott Gregory Blair Abbott Signed (1) The employer does not elect the employers’ liability coverage. Gregory J. Chenoweth gregcheno@gmail.com Same Indianola Warren Iowa Rebecca Sue Abbott Gregory Blair Abbott Signed
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
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
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
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
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
2074 2024-03-04 16:56 Anonymous (not verified) 94.188.207.224 IG painting Llc Limited Liability Company 416 51st ST West des moines,IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-01 antonio J Iglesias antonio_joserene@hotmail.com west Des moines polk iowa Raul Gomez Bruno Cruz Signed (1) The employer does not elect the employers’ liability coverage. Antonio J Iglesias antonio_joserene@hotmail.com not relationship West des Moines polk iowa Raul Gomez Bruno cruz Signed
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
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
1270 2022-08-19 08:35 Anonymous (not verified) 75.162.65.221 Tom Wilkinson Proprietorship 621 Depot St, Kellogg, IA 50135 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Tom Wilkinson tomwilkinson4588@yahoo.com Kellogg Jasper Iowa Randy Lacina Laura Lacina Signed (1) The employer does not elect the employers’ liability coverage. Tom Wilkinson tomwilkinson4588@yahoo.com Self Kellogg Jasper Iowa Randy Lacina Laura Lacina Signed
1271 2022-08-19 08:40 Anonymous (not verified) 75.162.65.221 William Ryerson Proprietorship 15423 Aurora Ave, 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. 2022-08-19 William Ryerson churchgirl488@yahoo.com Urbandale Dallas Iowa Randy Lacina Laura Lacina Signed (1) The employer does not elect the employers’ liability coverage. William Ryerson churchgirl488@yahoo.com Self Urbandale Dallas Iowa Randy Lacina Laura Lacina Signed
1272 2022-08-19 09:36 Anonymous (not verified) 75.162.65.221 William Jones Limited Liability Company 1639 E 13th 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. 2022-08-19 William Jones billjones1229@yahoo.com Des Moines Polk Iowa Randy Lacina Laura Lacina Signed (1) The employer does not elect the employers’ liability coverage. William Jones billjones1229@yahoo.com Self Des Moines Polk Iowa Randy Lacina Laura Lacina 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
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
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
1627 2023-05-08 13:43 Anonymous (not verified) 94.188.205.169 CR TOTAL PLUMBING, INC. Limited Liability Company 8190 Southern Hills Circle, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-05 Cory Ranson crpipes2@yahoo.com Dubuque Dubuque Iowa Randi Taylor Michelle Woodman Signed (1) The employer does not elect the employers’ liability coverage. CR Total Plumbing, Inc crpipes2@yahoo.com Owner Dubuque Dubuque Iowa Randi Taylor Michelle Woodman Signed
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
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
696 2021-10-28 10:33 Anonymous (not verified) 173.18.85.215 Saunders Construction Proprietorship 7304 SW 14th St Des Moines Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-28 Charles A Saunders charlessaunders901@gmail.com Des Moines IA United States Ramona Mitchell Rasheedah Gasaway Signed (1) The employer does not elect the employers’ liability coverage. Charles Saunders charlessaunders901@gmail.com Owner Des Moines Polk Iowa Ramona Mitchell Rasheedah Gasaway Signed
701 2021-10-29 18:35 Anonymous (not verified) 173.18.85.215 Saunders Construction Proprietorship 7304 SW 14th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-29 Charles Saunders charlessaunders901@gmail.com Des Moines Iowa Iowa Ramona Mitchell Rasheedah Gasaway Signed (1) The employer does not elect the employers’ liability coverage. Charles Saunders charlessaunders901@gmail.com Owner Des Moines IA United States Ramona Mitchell Rasheedah Gasaway Signed
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
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
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
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
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
1901 2023-11-10 07:08 Anonymous (not verified) 94.188.205.174 Elegance Exteriors Limited Liability Company 1236 11th Ave N I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. 2023-11-10 Tre Trotter Tre@eleganceexteriors.com Fort Dodge Webster Iowa Kyle Grell Raenell Richardson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Hiscox Inc. contact@hiscox.com None Atlanta Fulton Georgia Raenell Richardson Kyle Grell Signed
1886 2023-10-31 15:53 Anonymous (not verified) 94.188.205.176 CEM Businesses LLC Limited Liability Company 608 Evergreen Cir Nw Bondurant, IA 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-31 Dane McDonald dane.mcdonald@stellar-solar.net Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
1887 2023-10-31 15:57 Anonymous (not verified) 94.188.207.227 CEM BUSINESSES LLC Limited Liability Company 608 evergreen cir nw Bondurant, IA 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-31 Dustin Rudolph dmrudo@gmail.com Des Moines Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
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
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
1084 2022-05-02 15:23 Anonymous (not verified) 173.23.196.11 Sweet Green Arborist Services, LLC Limited Liability Company 804 W. Briggs Ave, Fairfield, IA 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-02 Andrew Forest Nash sweetgreenarborist@gmail.com Fairfield Jeffereson Iowa Eli Morgan Rachel Morgan Signed (1) The employer does not elect the employers’ liability coverage. Andrew Nash anash66@gmail.com same Fairfield Jeffereson Iowa Rachel Morgan Eli Morgan Signed
27 2020-01-06 09:17 Anonymous (not verified) 24.149.10.119 Miss Wonderful LLC Limited Liability Company 216 Main St Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 Ann Eastman misswonderful216@gmail.com Cedar Falls Black Hawk IA Rachel Lee Ann Remmert Signed (1) The employer does not elect the employers’ liability coverage. Ann Eastman misswonderful216@gmail.com Owner Cedar Falls Black Hawk IA Rachel Lee Ann Remmert Signed
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
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
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
1095 2022-05-12 13:20 Anonymous (not verified) 173.31.29.53 Leaf cutter protection Limited Liability Company 4146 East 23rd Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-05-12 Gideon Lagat gsaina78@gmail.com Des Moines IA United States Priscilla saina Cosmas nyaika Signed (1) The employer does not elect the employers’ liability coverage. Mark rond mbond@leaffilter.com Regional installation Manager Grimes Polk Iowa Priscilla saina Cosmas nyaika Signed
1970 2023-12-29 10:01 Anonymous (not verified) 94.188.205.168 Beatrice Banura Proprietorship 14511 Bentwood Dr, Urbandale IA 50323 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-29 Beatrice Banura banurabeatrice4@gmail.com Urbandale Dallas IA Priscilla Saina Gideon Saina Signed (1) The employer does not elect the employers’ liability coverage. Beatrice Banura banurabeatrice4@gmail.com Self employed Urbandale IA IA Priscilla Saina Gideon Saina Signed
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
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
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
1434 2023-01-31 07:12 Anonymous (not verified) 162.233.75.173 abc Proprietorship 1122 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-31 Brian Yurko byurko714@gmail.com Cedar Falls Black Hawk Iowa pete re pete Signed (1) The employer does not elect the employers’ liability coverage. LHE byurko@leafhome.com contractor Deerfield Beach Florida United States pete re pete Signed
2017 2024-02-01 15:23 Anonymous (not verified) 94.188.205.174 SolQ, LLC Limited Liability Company 184 N 100 E Suite A Logan UT 84321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-01 Casey Ryan Winger casey@solq.com Providence Cache UT Perry M. Koger Rebecca Koger Signed (1) The employer does not elect the employers’ liability coverage. Casey Ryan Winger casey@solq.com Owner Providence Cache Utah Perry M. Koger Rebecca Koger Signed
2018 2024-02-01 15:23 Anonymous (not verified) 94.188.205.177 SolQ, LLC Limited Liability Company 184 N 100 E STE A Logan, UT 84321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-01 David Bean dave@solq.com Clarkston Cache Utah Perry M. Koger Rebecca Koger Signed (1) The employer does not elect the employers’ liability coverage. David Bean dave@solq.com Owner Logan Cache Utah Perry M. Koger Rebecca Koger Signed
2019 2024-02-01 15:23 Anonymous (not verified) 94.188.205.167 SolQ LLC Limited Liability Company 184 N 100 E STE A Logan, UT 84321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-01 wyatt phelps wyatt@solq.com Eagle Mountain UT United States Perry M Koger Rebecca Koger Signed (1) The employer does not elect the employers’ liability coverage. wyatt phelps wyatt@solq.com Owner Eagle Mountain UT United States Perry M Koker Rebecca Koger 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
1605 2023-04-26 09:48 Anonymous (not verified) 94.188.207.229 Double Barrell Construction Proprietorship 1237 S 52nd St, #804, West Des Moines, IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Braedyn Baylor bbaylor66@gmail.com West Des Moines Polk IA Peggy Toft Rick Thompson Signed (1) The employer does not elect the employers’ liability coverage. Braedyn Baylor bbaylor66@gmail.com Owner West Des Moines Polk IA Peggy Toft Rick Thompson Signed
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
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
2160 2024-04-17 18:21 Anonymous (not verified) 94.188.207.226 QC Remodeling LLC Limited Liability Company 421 West Broadway, Ste 302 Council Bluffs, IA 51503 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-17 Fernando Ibarra ibarra_fernando@hotmail.com Rock Island Rock Island Illinois Paula Barria Louis Valencia Signed (1) The employer does not elect the employers’ liability coverage. Fernando Ibarra ibarra_fernando@hotmail.com Owner Rock Island Rock Island Illinois Paula Barria Louis Valencia Signed
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
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
1457 2023-02-15 18:06 Anonymous (not verified) 94.188.205.166 Chad Cowan Limited Liability Company 2108 Locust St West Des Moines IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Chad Stuart Cowan chad@bigroofing515.com West Des Moines Polk Iowa Paul Mouw Rob Schultz Signed (1) The employer does not elect the employers’ liability coverage. Chad Cowan rr2cw@yahoo.com Same West Des Moines IA United States Paul Mouw Rob Schultz Signed
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
1103 2022-05-15 09:56 Anonymous (not verified) 66.6.4.185 Christianson Trucking Inc., Owner Operator Proprietorship 2134 Lakeview Lane Gary SD 57237 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-08 Christianson Trucking Inc., Paul Christianson Owner paulyc63@outlook.com Gary Deuel South Dakota Paul Christianson Nancy Christianson Signed (1) The employer does not elect the employers’ liability coverage. Christianson Trucking Inc., Paul Christianson Owner paulyc63@outlook.com Self Gary Deuel South Dakota Paul Christianson Nancy Christianson Signed
1526 2023-03-21 12:24 Anonymous (not verified) 94.188.207.223 Quad Cities Transport Inc Proprietorship 1106 46th ave Rock Island IL 61201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-21 Howard Davis qctranaportinc@gmail.com East Moline Rock Island Illinois Ricky Oconner Patrick Watkins Signed (1) The employer does not elect the employers’ liability coverage. Howard Davis hdenterprisesinc14@gmail.com Owner East Moline Rock Island Illinois Patrick Watkins Ricky Oconner Signed
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
1847 2023-09-18 18:20 Anonymous (not verified) 94.188.205.168 William O'Brien Proprietorship 1069 Yukon Ave Sumner Iowa 50674 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 William Charles O'Brien wcobrien63@gmail.com Sumner Bremer Iowa Patrick B Dillon Christina Rader Signed (1) The employer does not elect the employers’ liability coverage. William Charles O'Brien wcobrien63@gmail.com self Sumner Bremer Iowa Patrick B Dillon Christina Rader 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
1370 2022-11-13 19:49 Anonymous (not verified) 174.213.144.30 Iowa’s Gutter Specialist Limited Liability Company 1390 Lark Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-21 Dustin Halverson dh42312695@gmail.com Hampton IA United States Patricia Reynolds Heather Halverson Signed (1) The employer does not elect the employers’ liability coverage. Dustin Halverson dh42312695@gmail.com Owner Hampton IA United States Patricia Marie Reynolds Heather Marie Halverson Signed
255 2020-09-11 13:42 Anonymous (not verified) 173.190.65.6 A Fisk Trucking, LLC Limited Liability Company PO Box 332, Strawberry Point, IA 52076 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-14 Andrew Fisk afisktrucking@gmail.com Strawberry Point Clayton Iowa Pamela Vaske Crystal Thole Signed (1) The employer does not elect the employers’ liability coverage. A Fisk Trucking, LLC afisktrucking@gmail.com Member/Manager Strawberry Point Clayton Iowa Pamela Vaske Crystal Thole Signed
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
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
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
2026 2024-02-07 08:32 Anonymous (not verified) 94.188.205.169 Strong Fencing & Decking LLC Limited Liability Company 343 59th Street Des Moines Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 Jacob James Strong strongfencingdecking@gmail.com Des Moines Polk Iowa Paige Crowley Jacob Waugh Signed (1) The employer does not elect the employers’ liability coverage. Jacob Strong strongfencingdecking@gmail.com Owner Des Moines Polk Iowa Paige Crowley Jacob Waugh Signed
1361 2022-11-07 09:14 Anonymous (not verified) 65.144.174.26 Rm Tile Marble LLC Limited Liability Company 2051 King Ave Apt 1, Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-07 Tony Funes balmore.funes76@icloud.com Des Moines Polk IA Osman Sarceno Gonzalez Nelson Hermanez Signed (1) The employer does not elect the employers’ liability coverage. RM Tile Marble LLC balmore.funes76@icloud.com Self Des Moines Polk IA Osman Sarceno Gonzalez Nelson Hermanez 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
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
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
1387 2022-12-10 22:39 Anonymous (not verified) 98.156.163.144 Springfield Staffing Solution Limited Liability Company 14918 Tuff Rd, Manor TX 78653 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-10 Beluchukwu Ebede admin@springfield-staffing.com Manor Travis United States Oluchukwu Nwokoye Beluchukwu Ebede Signed (1) The employer does not elect the employers’ liability coverage. Beluchukwu Ebede admin@springfield-staffing.com Self Manor Travis United States Oluchukwu Nwokoye Beluchukwu Ebede Signed
164 2020-05-26 10:30 Anonymous (not verified) 166.182.80.35 T.W. Barton Restoration Service Proprietorship 2704 Cass Avenue Mount Pleasant, Iowa 52641 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Todd William Barton II twbartonrestoration@yahoo.com Mount Pleasant Henry Iowa Olivia Grace Barton Todd William Barton Sr. Signed (1) The employer does not elect the employers’ liability coverage. Todd William Barton II twbartonrestoration@yahoo.com Self Mount Pleasant Henry Iowa Olivia Grace Barton Todd William Barton Sr. 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
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
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
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
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
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
1818 2023-08-25 15:16 Anonymous (not verified) 94.188.207.224 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 Yenifer Yomara Hernandez Solis 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 Marin Grjrd808504@outlook.com member Cedar Falls Black Hawk Iowa Noemi Guerrero Andres B Montoya 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
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
328 2020-11-26 12:28 Anonymous (not verified) 174.198.82.38 Duke millwright doing business as duke & sons Limited Liability Company 3264 e Payton ave Des Moines iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-11-26 Jeremiah duke jpduke24.7.365@gmail.com Des Moines Polk county Iowa Daniel Patrick Hemann Nikki Marie Harvey Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Diana duke dukemillwright@gmail.com Self Des Moines Polk Iowa Nikki Marie Harvey Daniel Patrick Hemann Signed
1340 2022-10-18 17:03 Anonymous (not verified) 166.181.89.97 Stevens mobile welding services LLC Limited Liability Company 5645 se 56th st. Carlisle, IA 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-18 Daniel Robert Stephens dannystephens303@gmail.com Carlisle Polk Iowa Nikita Marie Knapp Stacy Robin Stephens Signed (1) The employer does not elect the employers’ liability coverage. Daniel Robert Stephens dannystephens303@gmail.com Owner Carlisle Polk Iowa Nikita Marie Knapp Stacy Robin Stephens Signed
784 2021-12-09 09:03 Anonymous (not verified) 97.64.139.42 JZ INC Limited Liability Company 2509 Ne 10th CT Grimes Iowa 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-08 James Scott Zastrow Zastrow74@gmail.com Grimes IA United States NIcole Zastrow Kevan Wiggins Signed (1) The employer does not elect the employers’ liability coverage. James scott Zastrow loffredon@aol.com Self Grimes IA United States nicole zastrow Kevan wiggins Signed
2020 2024-02-02 07:14 Anonymous (not verified) 94.188.207.230 SM4 Consulting LLC Limited Liability Company 503 E 6TH ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-02 Chad Smith sm4consultingllc@gmail.com PRAIRIE CITY Jasper Iowa Nicole Smith Maybelle Smith Signed (1) The employer does not elect the employers’ liability coverage. Chad Smith sm4consultingllc@gmail.com self PRAIRIE CITY Jasper Iowa Nicole Smith Maybelle Smith Signed
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
1614 2023-04-27 15:18 Anonymous (not verified) 94.188.205.177 Crawford Construction Services LLC Limited Liability Company 1018 Creston Ave, Des Moines, Ia 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-27 Casey D Crawford crawfordcasey8824@gmail.com Des Moines Polk Iowa Nicole Powell Steve Crawford Signed (1) The employer does not elect the employers’ liability coverage. Casey D Crawford crawfordcasey8824@gmail.com Owner Des Moines Polk Iowa Nicole Powell Steve Crawford Signed
1766 2023-07-28 09:33 Anonymous (not verified) 94.188.205.177 Kleckner Trucking LLC Limited Liability Company 3780 March Ave 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. 2023-07-28 Tracy Kleckner klecknertrucking8710@hotmail.com Osage Mitchell Iowa Nicole Kleckner Tanya Kleckner Signed (1) The employer does not elect the employers’ liability coverage. L.R. Falk Construction jeannie@lrfalk.com dump truck hauler Osage Mitchell Iowa Nicole Kleckner Tanya Kleckner Signed
946 2022-03-04 10:43 Anonymous (not verified) 173.26.213.159 InTuition Painting & Design Proprietorship 2244 East 46th Place Davenport Iowa, 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-04 Brian J Bourke brianbourke@mediacombb.net Davenport Scott IA Anna E. Bourke Nicole K. Bourke Signed (1) The employer does not elect the employers’ liability coverage. Brian Bourke intuitionpainting@mediacombb.net Self Davenport Iowa Scott Iowa Nicole K. Bourkeq Anna E. Bourke Signed
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
22 2020-01-02 14:52 Anonymous (not verified) 173.17.129.166 Dan & Sarah Gudenkauf Proprietorship 3277 180th Ave, Ryan, IA 52330 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-02 Sarah Gudenkauf dandselectricmotor@gmail.com Ryan Delaware Iowa Nicole Almburg Kevin Corn Signed (1) The employer does not elect the employers’ liability coverage. Sarah Gudenkauf dandselectricmotor@gmail.com Owner Ryan Delaware Iowa Nicole Almburg Kevin Corn Signed
23 2020-01-02 14:54 Anonymous (not verified) 173.17.129.166 Dan Gudenkauf Proprietorship 3277 180th Ave, Ryan, IA 52330 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-02 Dan Gudenkauf dandselectricmotor@gmail.com Ryan Delaware Iowa Nicole Almburg Kevin Corn Signed (1) The employer does not elect the employers’ liability coverage. Dan Gudenkauf dandselectricmotor@gmail.com Owner Ryan Delaware Iowa Nicole Almburg Kevin Corn Signed
890 2022-02-03 15:11 Anonymous (not verified) 173.23.180.117 E.A. Electric LLC Limited Liability Company 1065 South Hill Dr, Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-03 Emin Alibegic emin.alibegic@yahoo.com Waterloo Black Hawk Iowa Nickole Pry Christine Willis Signed (1) The employer does not elect the employers’ liability coverage. Emin Alibegic emin.alibegic@yahoo.com Same Person Waterloo Black Hawk Iowa Nickole Pry Christine Willis Signed
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
203 2020-07-15 09:39 Anonymous (not verified) 166.181.66.222 High Caliber Fiber Limited Liability Company 2958 110th ave masonville IA, 50654 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-15 Chris cooper chris_cooper@highcaliberfiber.com Masonville Delaware Iowa Nick beranek Nicole kintzle Signed (1) The employer does not elect the employers’ liability coverage. Chris Cooper chris_cooper@highcaliberfiber.com N/A Masonville Delaware Iowa Nick beranek Nicole kintzle Signed
211 2020-07-20 15:30 Anonymous (not verified) 138.43.237.249 High Caliber Fiber Limited Liability Company 2958 110th Ave Masonville IA 50654 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-20 Chris Chris_cooepr@highcaliberfiber.com masonville Delaware IA NIck Beranek Nicole KIntzle Signed (1) The employer does not elect the employers’ liability coverage. Chris Cooper Chris_cooper@highcaliberfiber.com Self Masonville Delaware IA Nick Beranek Nicole Kintzle Signed
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
981 2022-03-16 13:51 Anonymous (not verified) 192.95.125.117 W.S. Amsden Proprietorship 405 E 4th Street 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. 2022-03-16 William Shane Amsden nmckenna@fsb-vinton.com Vinton Benton Iowa Nichole M McKenna Teresa Wehage Signed (1) The employer does not elect the employers’ liability coverage. William Shane Amsden nmckenna@fsb-vinton.com Self Vinton Benton Iowa Nichole M McKenna Terie Wehage Signed
685 2021-10-20 14:14 Anonymous (not verified) 65.144.174.26 william c sawhill Proprietorship 1625 Delaware Ave, Des Moines, 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. 2021-10-20 William C Sawhill workorders@shoproyalflooring.com Des Moines Polk Iowa Nicholas W Sawhill Jenny M Steben Signed (1) The employer does not elect the employers’ liability coverage. William C Sawhill workorders@shoproyalflooring.com Self Des Moines Polk Iowa Nicholas W Sawhill Jenny M Steben Signed
2164 2024-04-19 13:52 Anonymous (not verified) 94.188.205.167 RKB Designs LLC Limited Liability Company 4333 Cedar St, Davenport, IA 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-19 Ashley Rocca roccafive@gmail.com Davenport IA United States Nicholas Rocca Joni Long Signed (1) The employer does not elect the employers’ liability coverage. Ashley Rocca roccafive@gmail.com Self Davenport IA United States Nicholas Rocca Joni Long Signed
901 2022-02-06 16:48 Anonymous (not verified) 50.83.154.236 Cole Jurgle Proprietorship 409 West riverside drive prophetstown IL 61277 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-05 Cole Alexander Jurgle cole.jurgle@gmail.com Prophetstown Whiteside Illinois Nicholas Ray Jurgle Misty Ann Jurgle Signed (1) The employer does not elect the employers’ liability coverage. Cole Alexander Jurgle cole.jurgle@gmail.com self Prophetstown Whiteside Illinois Nicholas Ray Jurgle Misty Ann Jurgle Signed
87 2020-03-11 15:42 Anonymous (not verified) 50.105.78.41 Al's Aerial Spraying, LLC Limited Liability Company 3473 N Shepardsville Rd, Ovid MI 48866 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-11 Albert Edward Schiffer Al400@aol.com Ovid Cliinton Michigan Seth Alexander Nicholas Crofoot Signed (1) The employer does not elect the employers’ liability coverage. Albert Edward Schiffer Al400@aol.com Boss Ovid Clinto Michigan Nicholas Crofoot Nicholas Crofoot Signed
888 2022-02-03 14:40 Anonymous (not verified) 174.215.230.111 Blakesley Enterprise Proprietorship 609 Center St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-03 William Blakesley Blakesleyb@msn.com Reinbeck Iowa Iowa Nichelle Blakesley Christine Willis Signed (1) The employer does not elect the employers’ liability coverage. William Blakesley Blakesleyb@msn.com Owner Reinbeck Iowa Iowa Nichelle Blakesley Christine Willis 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
2102 2024-03-18 10:56 Anonymous (not verified) 94.188.207.228 NBJ Construction LLC Limited Liability Company 2536 Capitol Ave Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-18 Byron Jose Hernandez Nunez bjhernandez198807@gmail.com Des Moines Polk Iowa Nathan Miller Greg Beck Signed (1) The employer does not elect the employers’ liability coverage. NBJ Construction LLC bjhernandez198807@gmail.com Owner Des Moines Polk Iowa Nathan Miller Greg Beck Signed
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
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
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
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
382 2021-02-02 13:19 Anonymous (not verified) 192.30.185.142 Double D Weatherization Proprietorship 2069 Glenn Ellen Rd, Sergeant Bluff, IA 51054 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-02 Dale Gernhart lakehome@longlines.com Sergeant Bluff Woodbury IA Nate Blaeser Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Dale Gerhart lakehome@longlines.com Self Sergeant Bluff Woodbury IA Nate Blaeser Jennie Ebner Signed
1727 2023-07-07 18:26 Anonymous (not verified) 94.188.205.169 D&E LLC DBA Kanesville Valley Limited Liability Company P.O. Box 337 Council Bluffs, IA, 51502 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-07 Edward Gregory eddegregory@gmail.com Council Bluffs Pottawattamie Iowa Natasha Gregory Stanley Gregory Signed (1) The employer does not elect the employers’ liability coverage. Edward Gregory eddegregory@gmail.com Self Council Bluffs Pottawattamie Iowa Natasha Gregory Stanley Gregory Signed
1858 2023-10-03 13:29 Anonymous (not verified) 94.188.207.223 Quad city drywall Solutions LLC Limited Liability Company 5804 n thornwood ave Davenport iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-03 Erivan Emmanuel Montalvo Delcompare montalvobills6@gmail.com Davenport Scott Iowa Natalia Ann Montalvo Juan Portela Signed (1) The employer does not elect the employers’ liability coverage. Erivan Emmanuel Montalvo Delcompare montalvobills6@gmail.com Owner Davenport Scott Iowa Natalia Montalvo Juan Portela Signed
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
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
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
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
781 2021-12-08 08:41 Anonymous (not verified) 172.58.87.49 Diggins Installations Proprietorship 1619 48th st Des moines ia 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-06 Danny Allan Diggins ddigdan@gmail.com Des Moines Polk 1619 48th st Nancy Davis Angie Pilcher Signed (1) The employer does not elect the employers’ liability coverage. Danny Diggins ddigdan@gmail.com Self Des moines Polk Ia Nancy Davis Angie pilcher Signed
1262 2022-08-16 12:52 Anonymous (not verified) 74.137.151.70 Golds Custom Grading LLC Limited Liability Company Po Box 114 Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-16 Brad Carlson brad_carlson@gmail.com Spencer Clay Iowa Thomas Dunn Nancy Cassa Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Thomas Dunn TDUNN@THOMASBRADLEYINSURANCE.COM Agent Madison Dane Wisconsin Nancy Cassa Brad Carlson Signed
360 2021-01-12 12:08 Anonymous (not verified) 75.162.189.102 Super Green Plus Llc Limited Liability Company 3020 SE 5th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-12 Damon Berry theatvfan@gmail.com Des Moines IA United States Naki Brown Nakima Brown Signed (1) The employer does not elect the employers’ liability coverage. Super Green Plus theatvfan@gmail.com owner Des Moines IA United States Naki Brown Nakima Brown Signed
341 2020-12-23 08:52 Anonymous (not verified) 174.243.82.219 Jason D Struchen Proprietorship 1778 210th St Webster City, IA 50595 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-23 Jason David Struchen steruchen75@gmail.com Webster City Hamilton Iowa NA NA Signed (1) The employer does not elect the employers’ liability coverage. Jason D Struchen struchen75@gmail.com Same Webster City Hamilton Iowa NA NA Signed
1569 2023-04-12 16:19 Anonymous (not verified) 94.188.205.166 Leaf home solutions llc Limited Liability Partnership 1595 Georgetown rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-11 Gustavo Lopez Glopez2616@gmail.com Des Moines IA IA Ricardo lopez Maria lopez Signed (1) The employer does not elect the employers’ liability coverage. N/a sewell@leafhome.com N/a Na Na Na Na Na Signed
1825 2023-08-30 11:16 Anonymous (not verified) 94.188.207.225 Quad City Glass Proprietorship 1330 N Harrison St. Davenport, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-30 Jacob Brown quadcityglass@gmail.com Davenport Scott IOWA na na Signed (1) The employer does not elect the employers’ liability coverage. Quad City Glass Quadcityglass@gmail.com employee Davenport Scott IOWA na na Signed
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
1128 2022-05-26 11:11 Anonymous (not verified) 174.213.144.187 Leaf Filter Limited Liability Company 3060 se grimes blvd suite 100-300 Grimes iowa 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-24 Jason charlet jasonstreeservice2014@gmail.com Minburn Dallas Iowa Kami lillibridge Dale charlet Signed (1) The employer does not elect the employers’ liability coverage. N/a jasoncharlet703@gmail.com N/a N/a N/a N/a N/a N/a Signed
1137 2022-06-01 09:05 Anonymous (not verified) 63.170.122.111 sanchez framing construction llc Limited Liability Company 113 e a st west liberty, ia 52776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-01 Cindy Sanchez sanchezframingconst.llc@gmail.com west liberty muscatine iowa patricia verdines yajahira estrada Signed (1) The employer does not elect the employers’ liability coverage. n/a sanchezframingconst.llc@gmail.com n/a n/a n/a n/a n/a n/a Signed
1321 2022-09-26 08:16 Anonymous (not verified) 204.141.215.159 Leaf filter Limited Liability Company 615 J Ave NE Cedar Rapids, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-26 Dustin Hansen dhansen0925@gmail.com Marion Linn Iowa Audrianna Cleveland Trevor Frondle Signed (1) The employer does not elect the employers’ liability coverage. Leaf filter sewell@leafhome.com N/a Cedar rapids Linn Iowa N/a N/a Signed
1384 2022-12-08 13:11 Anonymous (not verified) 172.58.81.43 Sehic G&S, LLC. Limited Liability Company 4201 62nd st apt 4 Urbandale Ia 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-09 Bajro sehic kalesija20@gmail.com Urbandale Polk Iowa N/A N/A Signed (1) The employer does not elect the employers’ liability coverage. Bajro sehic kalesija20@gmail.com Owner Urbandale Polk Iowa N/A N/A Signed
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
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
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
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
1232 2022-07-28 18:27 Anonymous (not verified) 50.83.189.149 Eagle Construction Co LLC Limited Liability Company 1150 county line rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-28 Carlos Flores eagleconstruciontco.865@gmail.com Des Moines Warren Iowa Morgan Conrard Ronika Htu Signed (1) The employer does not elect the employers’ liability coverage. Carlos Flores eagleconstruciontco.865@gmail.com Owner Des Moines Warren IA Morgan Conrard Ronika Htu Signed
1536 2023-03-27 10:47 Anonymous (not verified) 94.188.205.174 Cecile C Knipp Limited Liability Company 1418 Oakcrest Dr., Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-27 Cecile C Knipp ceilknipp@gmail.com Waterloo Black Hawk Iowa Monica Robbins Anne Betts Signed (1) The employer does not elect the employers’ liability coverage. Cecile C Knipp christinaknipp@aol.com Self Waterloo Black Hawk Iowa Monica Robbins Anne Betts Signed
247 2020-08-26 20:00 Anonymous (not verified) 67.132.237.42 OPN Renovations LLC Limited Liability Company 1721 63rd St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-26 Haruko Nakata harunakata@hotmail.com Des Moines Iowa United States Monica Parra Oscar D Perez Signed (1) The employer does not elect the employers’ liability coverage. Haruko Nakata harunakata@hotmail.com Single Member Des Moines Iowa United States Monica Parra Oscar D Perez Signed
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
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
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
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
537 2021-06-07 15:25 Anonymous (not verified) 66.188.136.150 Casey Young Proprietorship 10731 State Highway 118 Turrell, AR 72384 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-03 Casey Young kschumacher@tricorinsurance.com Turrell Crittenden AR Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Casey Young kschumacher@tricorinsurance.com Same Turrell Crittenden AR Mitch Kemp Shuree Behr Signed
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
539 2021-06-08 17:06 Anonymous (not verified) 66.188.136.150 Todd Sechler Proprietorship 505 5th Street 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. 2021-06-08 Todd Sechler kschumacher@tricorinsurance.com Wellman Washington IA Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Todd Sechler kschumacher@tricorinsurance.com Same Wellman Washington IA Mitch Kemp Shuree Behr Signed
553 2021-07-01 08:17 Anonymous (not verified) 66.188.136.150 Cody Belleville Proprietorship 57167 Copperdate Dr. Elkhart, IN 46516 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-30 Cody Belleville kschumacher@tricorinsurance.com Elkhart Elkhart IN Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Cody Belleville kschumacher@tricorinsurance.com Same Elkhart Elkhart IN Mitch Kemp Shuree Behr Signed
555 2021-07-06 12:06 Anonymous (not verified) 66.188.136.150 Damond Horner Proprietorship 44 East Grove Monroe, MI 48162 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-02 Damond Horner kschumacher@tricorinsurance.com Monroe Monroe MI Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Damond Horner kschumacher@tricorinsurance.com Same Monroe Monroe MI Mitch Kemp Cody McClain Signed
556 2021-07-07 09:16 Anonymous (not verified) 66.188.136.150 William Campbell Proprietorship 159 Friendly Blvd. Springfield, IL 62707 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-06 William Campbell kschumacher@tricorinsurance.com Springfield Sangamon IL Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. William Campbell kschumacher@tricorinsurance.com Same Springfield Sangamon IL Mitch Kemp Shuree Behr Signed
557 2021-07-07 09:51 Anonymous (not verified) 66.188.136.150 Andrew Thompson-Sutherland Proprietorship 3200 Daniel Lane Apt. 207 Monroeville, PA 15146 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-06 Andrew Thompson-Sutherland kschumacher@tricorinsurance.com Monroeville Allegheny PA Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Andrew Thompson-Sutherland kschumacher@tricorinsurance.com Same Monroeville Allegheny PA Mitch Kemp Shuree Behr Signed
558 2021-07-07 13:35 Anonymous (not verified) 66.188.136.150 Austin Kalfus Sr. Proprietorship 1203 Poppy Ave. Pensacola, FL 32507 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-07 Austin Kalfus Sr. kschumacher@tricorinsurance.com Pensacola Escambia FL Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Austin Kalfus Sr. kschumacher@tricorinsurance.com Same Pensacola Escambia FL Mitch Kemp Shuree Behr Signed
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
560 2021-07-08 08:46 Anonymous (not verified) 66.188.136.150 Darius Harvey Proprietorship 2738 E 53rd. Apt. 7 Davenport, IA 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-07 Darius Harvey kschumacher@tricorinsurance.com Davenport Scott IA Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Darius Harvey kschumacher@tricorinsurance.com Same Davenport Scott IA Mitch Kemp Shuree Behr Signed
561 2021-07-08 09:11 Anonymous (not verified) 66.188.136.150 Aaron Maldonado dba ATM Trucking Proprietorship 1011 Reynolds Drive, Charleston, IL 61920 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-07 Aaron Maldonado dba ATM Trucking kschumacher@tricorinsurance.com Charleston Coles IL Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Aaron Maldonado dba ATM Trucking kschumacher@tricorinsurance.com Same Charleston Coles IL Mitch Kemp Shuree Behr Signed
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
38 2020-01-18 12:15 Anonymous (not verified) 206.109.174.199 BJS Frenchies, LLC Limited Liability Company 20081 Highway J 46 Centerville Iowa 52544 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 J. Jamie Tracy jamiespuppies@yahoo.com Centerville Appanoose Iowa Misty O'Hair Casey Leach Signed (1) The employer does not elect the employers’ liability coverage. Bruce E Tracy jamiespuppies@yahoo.com Husband and Co Owner Centerville Appanoose Iowa Misty O'Hair Casey Leach Signed
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
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
1960 2023-12-16 11:58 Anonymous (not verified) 94.188.207.227 Landeros Framing Proprietorship 2418 E 37th Ct I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-16 Francisco Javier Landeros Garcia garcialanderosfranciscojavier@gmail.com Des Moines IA IA Mirna Ruby Jose Gaytan Signed (1) The employer does not elect the employers’ liability coverage. Francisco Javier Landeros Garcia garcialanderosfranciscojavier@gmail.com owner Des Moines IA IA Mirna Ruby Jose Gaytan Signed
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
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
1989 2024-01-16 17:13 Anonymous (not verified) 94.188.205.168 Xcel Electric LLC Limited Liability Company 1142 Columbus Dr Waterloo Ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-16 Haris Mumic h.mumic@hotmail.com Waterloo Black Hawk IA Minea Skrgic-Mumic Elvis Mumic Signed (1) The employer does not elect the employers’ liability coverage. Haris Mumic h.mumic@hotmail.com Owner/Employer waterloo Black Hawk IA Minea Skrgic-Mumic Elvis Mumic Signed
1115 2022-05-17 19:36 Anonymous (not verified) 173.23.50.204 Delgado Electrical Services Limited Liability Company 1210 Creston Ave Des Moines, Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-17 Cesar Delgado delgado.electrical@gmail.com Des Moines Polk Iowa Mike Willet Alex Segovia Signed (1) The employer does not elect the employers’ liability coverage. Cesar Delgado cesar.delgado31@yahoo.com Owner Des Moines Polk Iowa Mike Willet Alex Segovia Signed
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
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
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
576 2021-07-14 18:13 Anonymous (not verified) 69.169.10.40 J&M Excavation Inc. Limited Liability Company 411 Pine Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-14 Bruce Bilyeu jmexcavation@outlook.com Norwalk Warren IA Mike Petersen Dennis Bilyeu Signed (1) The employer does not elect the employers’ liability coverage. Bruce Bilyeu jmexcavation@outlook.com Owner Norwalk Warren IA Mike Petersen Dennis Bilyeu Signed
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
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
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
1662 2023-05-25 12:52 Anonymous (not verified) 94.188.205.176 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1418 NW Applewood St. Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike Kaut Adam Lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
1663 2023-05-25 12:56 Anonymous (not verified) 94.188.205.167 Affordable Painting and Renovations of Iowa LLC Limited Liability Company 1417 NW Applewood St. Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-25 Bryan Thieleke affordablerenoiowa@yahoo.com Ankeny Polk Iowa Mike kaut Adam lozano Signed (1) The employer does not elect the employers’ liability coverage. Bryan Thieleke affordablerenoiowa@yahoo.com Owner Ankeny Polk Iowa Mike kaut Adam lozano Signed
437 2021-03-16 18:31 Anonymous (not verified) 38.121.121.16 Thompsen Irrigation Proprietorship 16086 Missouri Ave Crescent IA 51526 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-17 James R Thompsen jthom76285@aol.com Crescent Pottawattamie Iowa Mike Harmon Ilene Harmon Signed (1) The employer does not elect the employers’ liability coverage. James R Thompsen jthom76285@aol.com self Crescent Pottawattamie Iowa Mike Harmon Ilene Harmon Signed
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
1029 2022-04-04 12:46 Anonymous (not verified) 174.215.242.124 Bonnie Seely Proprietorship 43 rainbow court se Cedar Rapids Iowa 52403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-04 Bonnie Elizabeth seely bseely4@gmail.com Cedar Rapids Linn Iowa Mikaela Seely Noah seely Signed (1) The employer does not elect the employers’ liability coverage. Bonnie Seely bseely4@gmail.com Self Cedar Rapids IA United States Mikaela Seely Noah Seely Signed
366 2021-01-18 18:32 Anonymous (not verified) 75.162.57.214 Affordable Exteriors, LLC Limited Liability Company 802 east COUNTY LINE RD #57 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-18 Destiny Moses Info@mktdsm.com DES MOINES IA United States Miguel Angel Garcia Ramirez Nelly Bekker Signed (1) The employer does not elect the employers’ liability coverage. Destiny Moses Info@mktdsm.com owner DES MOINES IA United States Miguel Garcia Nellie Bekker Signed
681 2021-10-19 15:44 Anonymous (not verified) 65.144.174.26 Humberto Albino Proprietorship 3914 Aurora Ave Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-19 Humberto Albino albinohumberto73@gmail.com Des Moines Polk Iowa Miguel Albino Jesus Albino Signed (1) The employer does not elect the employers’ liability coverage. Humberto Albino albinohumberto73@gmail.com Owner Des Moines Polk Iowa Miguel Albino Jesus Albino Signed
16 2019-12-31 08:54 Anonymous (not verified) 70.184.208.208 J & D Transportation Proprietorship 1125 Lew Ross Road Council Bluffs, IA 51501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-31 Clarence Cecil Stogdill jack@jdmmtrucking.com Council Bluffs Iowa United States Mickey Jerome Stogdill Laurie Jo Stogdill Signed (1) The employer does not elect the employers’ liability coverage. Clarence Cecil Stogdill jack@jdmmtrucking.com owner-same person Council Bluffs Iowa United States Mickey Jerome Stogdill Laurie Jo Stogdill Signed
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
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
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
852 2022-01-21 15:52 Anonymous (not verified) 75.162.3.62 Alternative Interventions, LLC Limited Liability Company 3116 Ingersoll, #4 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-21 Carla Olson altint3116@gmail.com West Des Moines Dallas United States Michelle Grandstaff Alexandra Killinger Signed (1) The employer does not elect the employers’ liability coverage. CARLA OLSON altint3116@gmail.com Owner DES MOINES Polk United States Michelle Grandstaff Alexandra Killinger Signed
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
1936 2023-12-04 10:22 Anonymous (not verified) 94.188.205.174 Turkey River Ag Sales LLC Limited Liability Company 614 Vernon Rd. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-04 David Ahern davidahern@turkeyriverag.com Cresco IOWA IOWA Michelle Ahern Alyse Ahern Signed (1) The employer does not elect the employers’ liability coverage. Turkey River Ag Sales LLC davidahern@turkeyriverag.com Owner Cresco Howard Iowa Michelle Ahern Alyse Ahern Signed
1085 2022-05-03 10:38 Anonymous (not verified) 65.144.174.26 Caleb Schroeder Proprietorship 4051 SW 56th St Des Moines, IA 50321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-03 Caleb Schroeder calebpschroeder@gmail.com Des Moines Polk Iowa Michele Schroeder Donald Schroeder Signed (1) The employer does not elect the employers’ liability coverage. Caleb Schroeder calebpschroeder@gmail.com Self Des Moines Polk Iowa Michele Schroeder Donald Schroeder Signed
811 2021-12-22 17:31 Anonymous (not verified) 166.181.85.89 Demmer Construction Proprietorship 203 Michigan Ave Farley, IA 52046 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-22 Charles Demmer charliedemmer@gmail.com Farley Dubuque Ia Michele Demmer Jennifer White Signed (1) The employer does not elect the employers’ liability coverage. Charles Demmer charliedemmer@gmail.com Self Farley Dubuque Ia Michele Kay Demmer Jennifer Marie White Signed
812 2021-12-22 17:31 Anonymous (not verified) 166.181.85.89 Demmer Construction Proprietorship 203 Michigan Ave Farley, IA 52046 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-22 Charles Demmer charliedemmer@gmail.com Farley Dubuque Ia Michele Demmer Jennifer White Signed (1) The employer does not elect the employers’ liability coverage. Charles Demmer charliedemmer@gmail.com Self Farley Dubuque Ia Michele Kay Demmer Jennifer Marie White Signed
1322 2022-09-27 11:31 Anonymous (not verified) 96.31.4.134 Owens Inspection Services Limited Liability Company 598 2nd Street SE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-01 Alexander Patrick Owe s ap_owens_14@yahoo.com Hospers Sioux Iowa Michael Vander Wilt Shane Meendering Signed (1) The employer does not elect the employers’ liability coverage. Donald Patrick Owens dpowens@premieronline.net Owner Sioux Center Sioux Iowa Michael Vander Wilt Shane Meendering Signed
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
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
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
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
893 2022-02-03 16:17 Anonymous (not verified) 173.30.138.148 Your Cleaning Solution LLC Limited Liability Company P.O. Box 176 Gilbertville IA 50634 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Tricia Olson toyourcleaningsolution@yahoo.com Gilbertville Black Hawk Ia Michael Olson Kathy Heilig Signed (1) The employer does not elect the employers’ liability coverage. Tricia Olson toyourcleaningsolution@yahoo.com Same person Gilbertville Black Hawk Ia Michael Olson Kathy Heilig 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
183 2020-06-12 08:23 Anonymous (not verified) 107.77.173.7 A&W Marble & Tile Proprietorship 5624 Sw 5Th Pl I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Wayne A Yergy wyergy@gmail.com Des Moines IA United States Michael L Smith Guy B Chaney Signed (1) The employer does not elect the employers’ liability coverage. Wayne Yergy wyergy@gmail.com Self Des Moines IA United States Michael L Smith Guy B Chaney 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
1784 2023-08-04 10:39 Anonymous (not verified) 94.188.205.175 Danny Davis Limited Liability Company 2733 Raccoon Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-04 Danny R Davis ddavis3243@yahoo.com Des Moines IA United States Michael Gatewood Brad Wheeler Signed (1) The employer does not elect the employers’ liability coverage. HD EXTERIORS LLC ddavis3243@yahoo.com Owner Des Moines IA United States Michael Gatewood Brad Wheeler Signed
389 2021-02-10 13:59 Anonymous (not verified) 173.24.190.134 Shamrock Lanes, LLC Limited Liability Company 1304 Broadway, PO Box 304, Emmetsburg IA 50536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-03 Cindy Flannegan cindylou1964@hotmail.com Emmetsburg Palo Alto Iowa Michael Flannegan Laura Sidles Signed (1) The employer does not elect the employers’ liability coverage. Cindy Flannegan cindylou1964@hotmail.com Member of LLC Emmetsburg Palo Alto Iowa Michael Flannegan Laura Sidles Signed
1867 2023-10-16 12:34 Anonymous (not verified) 94.188.205.176 North Bay Dock Service Proprietorship PO Box 374, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-16 Donald L. Johnson, Jr. djtjaj@outlook.com Spirit Lake Dickinson Iowa Michael Chozen April Bosma Signed (1) The employer does not elect the employers’ liability coverage. Teresa Johnson djtjaj@outlook.com bookkeeper Spirit Lake Dickinson Iowa Michael Chozen April Bosma Signed
1868 2023-10-16 12:36 Anonymous (not verified) 94.188.205.177 North Bay Dock Service, LLC Limited Liability Company PO Box 374, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-16 Teresa A. JOhnson NBDSLLC@gmail.com Spirit Lake Dickinson Iowa Michael Chozen April Bosma Signed (1) The employer does not elect the employers’ liability coverage. Teresa Johnson NBDSLLC@gmail.com Manager Spirit Lake Dickinson Iowa Michael Chozen April Bosma 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
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
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
28 2020-01-06 13:39 Anonymous (not verified) 108.178.203.226 MULLIS CATTLE LLC Limited Liability Company 2506 155TH ST, EARLVILLE IA 52041 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 NICOLAS MULLIS JAMES@CIOIA.COM GREELEY DELAWARE IOWA MERRI MOSER BRITTANY LANSING Signed (1) The employer does not elect the employers’ liability coverage. NICOLAS MULLIS JAMES@CIOIA.COM OWNER GREELEY DELAWARE IA MERRI MOSER BRITTANY LANSING Signed
29 2020-01-06 13:44 Anonymous (not verified) 108.178.203.226 MULLIS CATTLE LLC Limited Liability Company 2506 155TH ST, EARLVILLE IA 52041 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-06 DAVID MULLIS JAMES@CIOIA.COM EARLVILLE DELAWARE IOWA MERRI MOSER BRITTANY LANSING Signed (1) The employer does not elect the employers’ liability coverage. DAVID MULLIS JAMES@CIOIA.COM OWNER EARLVILLE DELAWARE IOWA MERRI MOSER BRITTANY LANSING Signed
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
334 2020-12-07 12:38 Anonymous (not verified) 173.19.190.160 Broadband Installations of Iowa LLC Limited Liability Company P.O. Box 728 Carroll, IA 51401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-07 Charles Wood cwood.bband@outlook.com CEDAR RAPIDS IA IA Eva Wood Tamara Wood Signed (1) The employer does not elect the employers’ liability coverage. Skyla Siech skylabbi@outlook.com Offcie Manager Ely Linn Iowa Melvin Harter Eddie Bell Signed
1197 2022-07-11 08:35 Anonymous (not verified) 107.127.35.22 Leaf Filter Limited Liability Partnership 3060 SE Grimes Blvd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 Jacqueline Martínez charamusca05erick@icloud.com West Des Moines United Stated Iowa Melvin Gomez Martín Martínez Signed (1) The employer does not elect the employers’ liability coverage. Leaf Filter support@leafhome.com Sub contractor Grimes United States Iowa Melvin Gomez Martín Martínez Signed
1362 2022-11-08 08:36 Anonymous (not verified) 157.52.56.205 Martin Clip & Trim LLC Proprietorship Box 383 Urbana Iowa 52345 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-08 Armin Martin arminbonnie@aol.com Urbana Benton Iowa Melissa Stieferman Christin Martin Signed (1) The employer does not elect the employers’ liability coverage. Armin Martin arminbonnie@aol.com Self Urbana Benton Iowa Melissa Stieferman Christin Martin Signed
704 2021-11-01 18:43 Anonymous (not verified) 157.52.56.205 Martin Clip & Trim LLC Limited Liability Company 204 Oak Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-30 Armin Harold Martin arminbonnie@aol.com Urbana Benton Iowa Melissa Linn Stieferman Bronna Mae Gubbels Signed (1) The employer does not elect the employers’ liability coverage. Armin Harold Martin arminbonnie@aol.com self Urbana Benton Iowa Melissa Linn Stieferman Bronna Mae Gubbels Signed
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
1859 2023-10-04 07:54 Anonymous (not verified) 94.188.205.167 Pacheco Constructrion Limited Liability Company 1614 Center Street, 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. 2023-10-04 Ulises Pacheco info@pachecoconstruction.com Des Moines Polk Iowa Melissa Gray Darci Rene Pacheco Signed (1) The employer does not elect the employers’ liability coverage. Ulises Pacheco info@pachecoconstruction.com Self Des Moines Polk Iowa Melissa Gray Darci Rene Pacheco Signed
1694 2023-06-16 14:37 Anonymous (not verified) 94.188.205.176 Leaf Home Solutions LLC Partnership 3060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-16 Caleb Brincks chbrincks@gmail.com 628 NE 56th St Ankeny IA, 50021 Polk County Iowa Melissa Brincks Anisha Moten Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. AFTON INC chbrincks@gmail.com Owner Ankeny Polk Iowa Melissa Brincks Anisha Moten Signed
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
2203 2024-05-06 12:44 Anonymous (not verified) 94.188.207.228 Cma landimprovments Limited Liability Company 530 50th pleasantville I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 Cody authier cauthier85@gmail.com Pleasantville Marion Iowa Melissa authier Valerie vanhelten Signed (1) The employer does not elect the employers’ liability coverage. Cody authier cauthier85@gmail.com Self Pleasantville Marion Iowa Melissa authier Valerie vanhelten Signed
2131 2024-04-02 10:28 Anonymous (not verified) 94.188.205.168 Driskell Spray, LLC Limited Liability Company 1279 300th Ave Sidney, IA 51652 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-22 Jamie Driskell driskell216@gmail.com Sidney Fremont Iowa Melinda Goy Rhett Goy Signed (1) The employer does not elect the employers’ liability coverage. Jamie Driskell driskell216@gmail.com owner Sidney Fremont Iowa Melinda Goy Rhett Goy Signed
1792 2023-08-08 20:19 Anonymous (not verified) 94.188.207.229 Faith Based Construction Limited Liability Company 6820 Holcomb Ave. Apt. 8 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-08 Toby Andrew Johns tobyjohns28@gmail.com URBANDALE Polk United States Melanie Jo Ayersman Emma Stover Signed (1) The employer does not elect the employers’ liability coverage. Toby Andrew Johns tobyjohns28@gmail.com self URBANDALE Polk United States Melanie Jo Ayersman Emma Stover Signed
635 2021-09-10 13:41 Anonymous (not verified) 166.181.84.226 JZH Roofing Specialists LLC Limited Liability Company 2127 Swan Dr, Norwalk, Iowa. 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-10 Jayme Alexander Christian Heiselman wrkhrd2plyhrd04@gmail.com Norwalk Warren Iowa Melanie Handy Jesse Hagge Signed (1) The employer does not elect the employers’ liability coverage. Jayme Alexander Christian Heiselman wrkhrd2plyhrd04@gmail.com Single member Norwalk Warren Iowa Melanie Handy Jesse Hagge Signed
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
587 2021-07-26 12:40 Anonymous (not verified) 172.56.7.208 Central Iowa Dict Cleaning Proprietorship 1414 Adventureland Dr #4206 Altoona IA 50009 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-26 Gary Gallagher ductclean@gmail.com Altoona Polk IA Meghan Militti Todd Nastase Signed (1) The employer does not elect the employers’ liability coverage. Gary Gallagher ductclean@gmail.com Self Altoona Polk IA Meghan Militti Todd Nastase Signed
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
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
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
198 2020-07-08 17:35 Anonymous (not verified) 162.218.47.214 Olsem Aerial Application Services LLC Limited Liability Company 34538 County Road 13 Westbrook MN 56183 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-08 Benjamin Olsem oaasllc@gmail.com Westbrook Cottonwood MN Megan Olsem Tobin Richards Signed (1) The employer does not elect the employers’ liability coverage. Benjamin Olsem oaasllc@gmail.com Owner/Self Westbrook Cottonwood MN Megan Olsem Tobin Richards Signed
529 2021-05-24 16:16 Anonymous (not verified) 67.230.239.111 Olsem Aerial Application Services LLC Limited Liability Company 34538 County Road 13 Westbrook, Minnesota 56183 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-24 Benjamin Olsem oaasllC@gmail.com Westbrook Cottonwood Minnesota Megan Olsem Jeff Oberg Signed (1) The employer does not elect the employers’ liability coverage. Olsem Aerial Application Services LLC oaasllc@gmail.com Owner/Self Westbrook Cottonwood Minnesota Megan Olsem Jeff Oberg Signed
932 2022-02-22 17:20 Anonymous (not verified) 72.212.49.250 Duane Bruxvoort Proprietorship 201 Park Lane, Pella, IA 50219 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-01 Duane L Bruxvoort duanebrux@gmail.com Pella Marion Iowa Megan Lee Pingel Dorothy Jean Bruxvoort Signed (1) The employer does not elect the employers’ liability coverage. Duane Bruxvoort duanebrux@gmail.com Self Pella Marion Iowa Megan Lee Pingel Dorothy Bruxvoort Signed
604 2021-08-14 11:18 Anonymous (not verified) 69.54.119.134 Robert Curry Limited Liability Company 10759 S 96th Ave W Prairie City IA 50228 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-14 Bob Curry Gardengal4205@gmail.com Prairie City IA United States Megan Irwin Rob Irwin Signed (1) The employer does not elect the employers’ liability coverage. Robert Curry Gardengal4205@gmail.com Self Prairie City IA United States Megan Irwin Rob Irwin Signed
322 2020-11-17 14:06 Anonymous (not verified) 208.126.118.26 Wada Farms Limited Liability Company 2428 270th st Grand Mound, IA 52751 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-17 Wade Smith wade.smith1110@gmail.com Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed (1) The employer does not elect the employers’ liability coverage. Wada Farms wade.smith1110@gmail.com self Grand Mound clinton Iowa Megan Fuglsang Jenny Gordon Signed
649 2021-09-21 13:15 Anonymous (not verified) 208.126.118.26 Wade Smith DBA WADA Farms Proprietorship 2428 270th st, Grand Mound, IA 52751 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. 2021-09-21 Wade Smith wade.smith1110@gmail.com Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Wade Smith wade.smith1110@gmail.com self Grand Mound Clinton Iowa Megan Fuglsang Jenny Gordon Signed
2134 2024-04-04 08:10 Anonymous (not verified) 94.188.205.169 TERRA CONSTRUCTION LLC Limited Liability Company 621 Oak Park Ave Des Moines, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-04 Bryce Shabazz block.radio@yahoo.com Des Moines Polk Iowa Megan Donigan George Hana Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jessica L Heller Jessica.heller@adp.com Insurance Agent Allentown Lehigh PA Megan Donigan George Hana Signed
756 2021-11-19 14:05 Anonymous (not verified) 65.144.174.26 Jaime Hernandez Lopez Proprietorship 223 N 9th Ave W, Newton, Iowa 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-19 Jaime Hernandez Lopez jaimehernandezlopez81@yahoo.com Newton Jasper Iowa Megan Ackerly Antonio Lopez Signed (1) The employer does not elect the employers’ liability coverage. Jaime Hernandez Lopez jaimehernandezlopez81@yahoo.com Self Newton Jasper Iowa Megan Ackerly Antonio Lopez Signed
1020 2022-03-29 16:53 Anonymous (not verified) 207.32.60.144 J.A. Dahlhauser, Ltd. Proprietorship 1741 Hwy. 7 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-29 Jaylin A. Dahlhauser jaydahlhauser@gmail.com Newell IA United States Matthew McClellan Gracelin R. Dahlhauser Signed (1) The employer does not elect the employers’ liability coverage. Jaylin A. DAhlhauser jaydahlhauser@gmail.com Owner Newell IA United States Matthew McClellan Gracelin R. Dahlhauser Signed
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
844 2022-01-20 08:55 Anonymous (not verified) 172.58.87.106 Barkley Coatings Limited Liability Company 305 E 20th St S I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-20 Heath barkleyheath@yahoo.com Newton United States Iowa Matthew Blunk Hailey Scott Signed (1) The employer does not elect the employers’ liability coverage. Heath Barkley barkleyheath@yahoo.com Owner Newton IA United States Matthew Blunk Hailey Scott Signed
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
1246 2022-08-08 12:33 Anonymous (not verified) 174.215.249.59 Dustin Rambo Proprietorship 4570, Hunter St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-07 Dustin Lee Rambo dlrambo80@gmail.com Palo USA IA Matt Lytle Jason Achenbach Signed (1) The employer does not elect the employers’ liability coverage. Dustin Rambo dlrambo80@gmail.com Self Palo USA IA Matt Lytle Jason Achenbach Signed
340 2020-12-18 08:37 Anonymous (not verified) 172.83.31.129 Todd Fisher DBA Lake Country Window Cleaning Proprietorship 1506 Willow Place, Clear Lake, IA 50428 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-12-18 Todd Fisher Lakecountrywindow@yahoo.com Clear Lake Cerro Gordo Iowa Matt Koch Deb Koch Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Todd Fisher lakecountrywindow@yahoo.com Same Clear Lake Cerro Gordo Iowa Matt Koch Deb Koch 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
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
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
566 2021-07-08 14:19 Anonymous (not verified) 50.82.130.211 Black Cat Ice Cream, LLC Limited Liability Company 1031 Office Park Road, Suite #4, West Des Moines IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-10 David Boelman cmins_re@mchsi.com Des Moines Polk Iowa Mary Brown Kaytee Stearns Signed (1) The employer does not elect the employers’ liability coverage. Black Cat Ice Cream, LLC cmins_re@mchsi.com Self Des Moines Polk Iowa Mary Brown Kaytee Stearns Signed
567 2021-07-08 14:22 Anonymous (not verified) 50.82.130.211 Black Cat Ice Cream, LLC Limited Liability Company 1031 Office Park Road, Suite #4, West Des Moines IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-10 Alex Carter cmins_re@mchsi.com Des Moines Polk Iowa Mary Brown Kaytee Stearns Signed (1) The employer does not elect the employers’ liability coverage. Black Cat Ice Cream, LLC cmins_re@mchsi.com Self Des Moines Polk Iowa Mary Brown Kaytee Stearns Signed
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
1068 2022-04-25 06:07 Anonymous (not verified) 172.58.84.213 Alondra Canedo Orta Limited Liability Company 4100 Hubbell Ave Apt#80 Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-25 Alondra Canedo Orta alondracanedo34@gmail.com Des Moines Polk county Iowa Marvin Bonilla Alondra Canedo Signed (1) The employer does not elect the employers’ liability coverage. Alondra Canedo Orta alondracanedo34@gmail.com Subcontractor Installer Des Moines Polk county Iowa Marvin Bonilla Alondra Canedo Signed
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
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
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
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
1670 2023-05-30 17:07 Anonymous (not verified) 94.188.207.226 Davis&Viteri LLC Limited Liability Company 1125 Florida ave apt 519 Ames Iowa 50014 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-30 Christopher Viteri davisviteri17@gmail.com Johnston Polk Iowa Labron davis Marshalle Coleman Signed (1) The employer does not elect the employers’ liability coverage. Marshalle coleman marshalle.coleman@yahoo.con Friend Ames Story Iowa Marshalle coleman Labron davis Signed
631 2021-09-02 22:46 Anonymous (not verified) 173.23.144.4 Lopez Framing LLC Limited Liability Company 566 walker st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-02 Diana A Garcia Lopez lopezframing0702@gmail.com Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed (1) The employer does not elect the employers’ liability coverage. Diana A Garcia Lopez lopezframing0702@gmail.com Owner Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed
1642 2023-05-12 07:29 Anonymous (not verified) 94.188.205.169 HARI SWAMI LLC Limited Liability Company 2759 Mt Pleasant St, Burlington, IA 52601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-12 BRANDON KELLY MARKWILLIAMSPRO@GMAIL.COM FRUIT HEIGHTS DAVIS UTAH MARK WILLIAMS GREG VANCAMP Signed (1) The employer does not elect the employers’ liability coverage. BRANDON KRLLY MARKWILLIAMSPRO@GMAIL.COM SELF FRUIT HEIGHTS DAVIS UTAH MARK WILLIAMS GREG VANCAMP Signed
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
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
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
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
1143 2022-06-06 15:48 Anonymous (not verified) 63.152.93.184 Adaptability Plus Limited Liability Company 904 W 4th 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. 2022-01-02 Timothy Combs tcombshd@gmail.com Cedar Falls Iowa United States Mark Moser Teresa Tjaden Signed (1) The employer does not elect the employers’ liability coverage. Timothy Combs tcombshd@gmail.com none Cedar Falls Black Hawk Iowa Mark Moser Teresa Tjaden Signed
1336 2022-10-17 12:42 Anonymous (not verified) 63.152.97.11 Adaptability Plus Llc Limited Liability Company 904 W 4th Street, 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. 2022-10-17 Timothy Combs timcombs@afiliowa.org Waterloo Iowa United States Mark Moser Teresa Tjaden Signed (1) The employer does not elect the employers’ liability coverage. Timothy Combs timcombs@afiliowa.org none Waterloo Iowa United States Mark Moser Teresa Tjaden Signed
2139 2024-04-08 10:35 Anonymous (not verified) 94.188.205.168 Professional Hardwood Floors LLC Limited Liability Company 14858 118th Ave, Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-08 Ivan Pilat professionalfloors@ymail.com Indianola Warren iowa Mark Kapysten Vladmir Orbedan Signed (1) The employer does not elect the employers’ liability coverage. Ivan Pilat professionalfloors@ymail.com Self Indianola Warren Iowa Mark Kapysten Vladmir Orbedan Signed
755 2021-11-19 13:25 Anonymous (not verified) 65.144.174.26 Central Iowa Insulation and Floors Inc Proprietorship 14858 118 Ave, Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-19 Ivan Pilat centraliowaif@gmail.com Indianola Warren Iowa Mark Kapustin Vladimir Orbinan Signed (1) The employer does not elect the employers’ liability coverage. Ivan Pilat centraliowaif@gmail.com Self Indianola Warren Iowa Mark Kapustin Vladimir Orbinan Signed
1018 2022-03-29 15:00 Anonymous (not verified) 97.125.143.50 Modified Originals of Winterset Limited Liability Company 128 S 3rd Ave, Winterset, IA 50273 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-29 Daniel Maiers Modifiedoriginals.winterset@gmail.com Winterset Iowa Iowa Mark Haddinger Josh Williams Signed (1) The employer does not elect the employers’ liability coverage. Dan Maiers Modifiedoriginals.winterset@gmail.com Self Winterset Iowa Iowa Mark Haddinger Josh Williamson Signed
1546 2023-03-29 20:53 Anonymous (not verified) 94.188.205.175 D2 Construction LLC Limited Liability Company 16192 Wendover Ave Madrid, Iowa 50156 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-29 Dillon Devine d2construction22@gmail.com Madrid Dallas Iowa Mark Devine Jodie Gumm Signed (1) The employer does not elect the employers’ liability coverage. Dillon Devine d2construction22@gmail.com Owner Madrid Dallas Iowa Mark Devine Jodie Gumm Signed
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
411 2021-02-22 15:58 Anonymous (not verified) 173.24.190.134 The Willow Tree Garden Center Limited Liability Company 2103 19rh Street, Emmetsburg IA 50536 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-22 Erica Janssen mrjanz13@gmail.com Emmetsburg Palo Alto Iowa Marilee Lace Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Erica Janssen mrjanz13@gmail.com Member of LLC Emmetsburg Palo Alto Iowa Marilee Lace Candie Clark Signed
1035 2022-04-05 12:03 Anonymous (not verified) 199.120.121.97 Bruce Peters Painting Proprietorship 53568 Rosewood Road, Walnut IA 51577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-05 Bruce Peters bpeters1992@yahoo.com Walnut Pottawattamie Iowa Marie Peters Angie Gettys Signed (1) The employer does not elect the employers’ liability coverage. Bruce Peters bpeters1992@yahoo.com self Walnut Pottawattamie Iowa Marie Peters Angie Gettys Signed
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
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
405 2021-02-17 11:04 Anonymous (not verified) 104.201.67.178 CYE Painting Limited Liability Company 5202 SE 31st Ct Des Moines,IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-17 CYE Painting marilopez9657@yahoo.com Des Moines Polk Iowa Maricela Lopez Cruz Cabrera Signed (1) The employer does not elect the employers’ liability coverage. Maricela Lopez marilopez9657@yahoo.com N/a Des Moines Polk IA Maricela Lopez Cruz Cabrera Signed
2148 2024-04-15 11:15 Anonymous (not verified) 94.188.207.224 Derek Fetzer Proprietorship 360 250th St, West Branch, IA 52358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-17 Dere W Fetzer kellylanz1967@gmail.com West Branch IA United States Maribelle Lund Carl Lund Signed (1) The employer does not elect the employers’ liability coverage. Derek Fetzer kellylanz1967@gmail.com Self West Branch IA United States Maribelle Lund Carl Lund Signed
1997 2024-01-25 11:09 Anonymous (not verified) 94.188.207.225 Abstract Associates of Iowa Inc. Proprietorship 822 Central Ave Ste 304 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. 2023-09-21 Ted Hugghins tjhugghins@abstractassociatesofiowa.com Fort Dodge Webster Iowa Mariah Ayala Bennett O'Connor Signed (1) The employer does not elect the employers’ liability coverage. Ted Hugghins tjhugghins@abstractassociatesofiowa.com President Fort Dodge Webster IA Mariah Ayala Bennett O'Connor Signed
1974 2024-01-04 13:12 Anonymous (not verified) 94.188.205.167 Cro Outdoor Services, LLC Limited Liability Company 1616 NW 78TH ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-20 Bojan Djukic Croodsia@gmail.com Clive Iowa United States Cezar Villalobos Maria Villalobos Signed (1) The employer does not elect the employers’ liability coverage. Evetee Villalobos e.villalobos91@gmail.com s/o Clive IA United States Maria Villalobos Cezar Villalobos Signed
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
1586 2023-04-19 08:38 Anonymous (not verified) 94.188.205.169 Arcos Siding, LLC Limited Liability Company 1429 22nd Street, Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-19 Alfredo Arco Cruz alfredoarcos13@gmail.com Des Moines Polk Des Moines Maria Sevillana Cruz Miguel Sevillana Signed (1) The employer does not elect the employers’ liability coverage. Alfredo Arcos Cruz alfredoarco13@gmail.com Self Des Moines Polk Iowa Maria Sevillana Cruz Miguel Sevillana Signed
2219 2024-05-10 10:20 Anonymous (not verified) 94.188.207.228 Froyo To Go, LLC Limited Liability Company 909 4th Ave. South, Denison, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-10 Derek Lambert drdereklambert@gmail.com Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed (1) The employer does not elect the employers’ liability coverage. Trevis Beeck trevis.beeck.u0ms@statefarm.com I am the State Farm Agent who is submitting the Business Policy Denison Crawford Iowa Maria Sandoval Nahomy Fernandez Alvarado Signed
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
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
612 2021-08-19 21:50 Anonymous (not verified) 50.82.65.174 33z Racing,, LLC Limited Liability Company 307 N Park Ave, New Sharon, Iowa 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-20 James Dean VanderBeek jvanderbeek@plbco.com New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Spouse New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed
613 2021-08-19 21:54 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, Iowa 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-20 Zackery J VanderBeek zackvanderbeek@gmail.com New Sharon Mahaska IA Margaret Ratcliff Billy Blake Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Mother New Sharon Mahaska IA Margaret Ratcliff Billy Blake Signed
2190 2024-04-29 09:28 Anonymous (not verified) 94.188.205.168 JOHNSON OHANA LLC Limited Liability Company 145 GREENBRIER DR, BURLINGTON, IA 52601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-29 JARED JOHNSON KONAOHANAICE@GMAIL.COM BURINGTON DES MOINES IOWA MARCY KNAUSS MATTHEW RINKER Signed (1) The employer does not elect the employers’ liability coverage. MAGGIE JOHNSON KONAOHANAICE@GMAIL.COM PARTNER/SPOUSE BURLINGTON DES MOINES IOWA MARCY KNAUSS MATTHEW RINKER Signed
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
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
584 2021-07-23 15:38 Anonymous (not verified) 75.162.41.54 Bradens Roofing & Construction LLc Limited Liability Company 2450 Hart Ave, Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-23 Arsenio Vargas avargas409@gmail.com Des Moines Polk Iowa Marc Black Jason Anderson Signed (1) The employer does not elect the employers’ liability coverage. Arsenio Vargas avargas409@gmail.com Owner Des Moines Polk Iowa Marc Black Jason Anderson Signed
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
349 2020-12-31 17:37 Anonymous (not verified) 107.77.161.33 JAG Painting Proprietorship 1423 des moines street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-31 Berenice Silva berenicesssvaldes@gmail.com Des moines Polk IA Manuel Aguilar Luis Garcia Signed (1) The employer does not elect the employers’ liability coverage. Berenice Silva berenicesssvaldes@gmail.com Owner Des moines Polk Iowa Manuel Aguilar Luis Garcia Signed
1069 2022-04-26 08:39 Anonymous (not verified) 174.198.72.171 GR Roofing Proprietorship 802 E County Line Rd Lot 137, Des Moines, Ia 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-26 Eleazar Guzman-Rios emmanuelgscop.1425@gmail.com Des Moines Polk Iowa Manny Socop Julio Andrew Signed (1) The employer does not elect the employers’ liability coverage. Eleazar Guzman-Rios emmanuelgscop.1425@gmail.com Owner Des Moines Polk Iowa Manny Socop Julio Andrews Signed
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
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
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
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
568 2021-07-09 09:26 Anonymous (not verified) 184.12.14.229 SS Docks LLC Limited Liability Company P.O. Box 561 Okoboji, IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-21 Jason Snow k.kooima@q.com Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jason Snow - SS Docks LLC k.kooima@q.com Owner Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed
570 2021-07-09 16:42 Anonymous (not verified) 184.12.14.229 SS Docks LLC Limited Liability Company P.O. Box 561 Okoboji, IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-21 Jason Snow kkooima@q.com Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jason Snow - SS Docks LLC kkooima@q.com Owner Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed
593 2021-08-03 12:29 Anonymous (not verified) 184.12.14.229 SS Docks LLC Limited Liability Company PO Box 561, Okoboji, IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-21 Jason Snow k.kooima@q.com Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jason Snow - SS Docks LLC k.kooima@q.com Owner Okoboji Dickinson Iowa Mabel Behnke Brandi Parks Signed
53 2020-02-06 11:09 Anonymous (not verified) 65.100.22.228 Bostian Captioning Service, Inc. Proprietorship 712 8th Avenue NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-06 Dana Bostian danabostian@msn.com Oelwein IA United States Lynne Koch Billie Winters Signed (1) The employer does not elect the employers’ liability coverage. Dana Bostian danabostian@msn.com President of Proprietorship Oelwein IA United States Lynne Koch Billie Winters Signed
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
85 2020-03-09 08:17 Anonymous (not verified) 198.167.182.164 Simply Anchored LLC dba Simply Mae's Limited Liability Company 601 Broad St, Story City, IA 50248 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-05 Jessi Kettenacker jessi@simplymaes.com Story City Story Iowa Lynn McKinney Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Jessi Kettenacker jessi@simplymaes.com Managing Member Story City Story Iowa Lynn McKinney Dyan Kriener Signed
86 2020-03-09 08:19 Anonymous (not verified) 198.167.182.164 Simply Anchored LLC dba Simply Mae's Limited Liability Company 601 Broad St, Story City, IA 50248 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-05 Cande Coulter cande@simplymaes.com Story City Story Iowa Lynn McKinney Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Candy Coulter cande@simplymaes.com Managing Member Story City Story Iowa Lynn McKinney Dyan Kriener Signed
1455 2023-02-15 11:44 Anonymous (not verified) 94.188.205.177 Bruce A. Nelson Proprietorship 300 Shetland Dr Nw Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Bruce A. Nelson sherylnelson15@yahoo.com Cedar Rapids Linn Iowa Lynn M Haigh David Reibsamen Signed (1) The employer does not elect the employers’ liability coverage. Sheryl Nelson sherylnelson15@yahoo.com Wife Cedar Rapids Linn Iowa Lynn M. Haigh David Reibsamen Signed
2097 2024-03-15 18:28 Anonymous (not verified) 94.188.205.176 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. (1) I am not electing the employers’ liability coverage. 2024-03-15 Tristan Anthony Siebrands omgservices@omgbros.org Waterloo USA Iowa Lynda C Bolin Kevin D Bolin Signed (1) The employer does not elect the employers’ liability coverage. Tristan Anthony Siebrands omgservices@omgbros.org Self Waterloo Black Hawk Iowa Lynda C Bolin Kevin D Bolin Signed
63 2020-02-17 16:05 Anonymous (not verified) 173.17.12.213 ANA GARCIA GONZALEZ Limited Liability Company 4023 14TH ST DES MOINES IOWA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-17 Ana Garcia Gonzalez gjeanettegonzalez@gmail.com DES MOINES POLK IOWA LUZ SAUCEDA SANDRA ISABEL SAUCEDA Signed (1) The employer does not elect the employers’ liability coverage. ANA GARCIA GONZALEZ GJEANETTEGONZALEZ@GMAIL.COM SELF DES MOINES POLK IA LUZ SOTELO SAUCEDO SANDRA ISABEL SAUCEDA Signed
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
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
274 2020-10-06 13:18 Anonymous (not verified) 174.250.65.147 Ddp construction Proprietorship 1923 63rd st. Urbandale , ia 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-06 Dustin a perry perrythedustin@gmail.com Urbandale Polk Iowa Luke jackson Loud jackson Signed (1) The employer does not elect the employers’ liability coverage. Dustin perry perrythedustin@gmail.com Owner Urbandale Polk Iowa Luke jackson Loyd jackson Signed
702 2021-11-01 09:23 Anonymous (not verified) 173.28.195.56 Garcia Snow Removal Limited Liability Company 213 E 7th Street, West Liberty, Iowa 52776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-01 Benji A Garcia garciabenji23@gmail.com West Liberty IA Norway Luis Ordenana-Choez Vicente Garcia Signed (1) The employer does not elect the employers’ liability coverage. Benji Garcia garciabenji23@gmail.com Member West Liberty Muscatine Iowa Luis Ordenana-Choez Vicente Garcia Signed
193 2020-06-24 11:13 Anonymous (not verified) 173.28.196.82 Gray Nation LLC DBA Gray Goat Tattoo Limited Liability Company 116 N 1st Street West Branch, Iowa 52358-9663 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-06-24 Elizabeth Gray beth.gray516@gmail.com West Branch Cedar Iowa Luis Ordenana Don Naugthon Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Elizabeth Gray beth.gray516@gmail.com LLC Member West Branch Cedar Iowa Luis Ordenana Don Naughton Signed
264 2020-09-21 13:26 Anonymous (not verified) 107.77.173.3 JAG Painting Proprietorship 1423 Des Moines Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-21 Berenice S Silva berenicesssvaldes@gmail.com Des Moines Polk Iowa Luis Garcia Maria Salas Signed (1) The employer does not elect the employers’ liability coverage. Berenice S Silva berenicesssvaldes@gmail.com Owner Des Moines Polk Iowa Luis Garcia Maria Salas Signed
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
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
810 2021-12-22 15:13 Anonymous (not verified) 167.142.30.134 Bouillon Lawn Care Proprietorship 3074 Lodge Ave Greene, IA 50636 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-22 Jerry Bouillon greeneflowerman@yahoo.com Greene Floyd Iowa Lucas Wedeking Misty Osborn Signed (1) The employer does not elect the employers’ liability coverage. Jerry Bouillon Greeneflowerman@yahoo.com Self Greene Floyd Iowa Lucas Wedeking Misty Osborn Signed
1577 2023-04-17 09:58 Anonymous (not verified) 94.188.205.167 Four Leaf LLC Limited Liability Company 11150 NE 72nd St Bondurant IA 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-17 Eric O'Shea Fourleaf2021@gmail.com Bondurant IA United States Lucas Gray Curt Decker Signed (1) The employer does not elect the employers’ liability coverage. Eric Michael O'Shea Fourleaf2021@gmail.com Owner Bondurant IA United States Lucas Gray Curt Decker Signed
461 2021-04-06 08:49 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-06 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
462 2021-04-06 08:56 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven,IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-06 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
975 2022-03-15 10:34 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
976 2022-03-15 10:44 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
1516 2023-03-14 09:00 Anonymous (not verified) 94.188.207.225 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-14 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
1517 2023-03-14 09:06 Anonymous (not verified) 94.188.207.230 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-14 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Louise Helmke Janice Henningsen Signed
1078 2022-04-28 16:04 Anonymous (not verified) 207.32.54.103 Juilfs Trucking Proprietorship 709 S Geneva St. Pomeroy, IA 50575 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-28 Terry Juilfs sarah_burke7274@hotmail.com Pomeroy Calhoun Iowa Lorie Gerdes Autumn Ramthun Signed (1) The employer does not elect the employers’ liability coverage. Terry Juilfs sarah_burke7274@hotmail.com Myself Pomeroy IA United States Lorie Gerdes Autumn Ramthun Signed
1541 2023-03-29 11:21 Anonymous (not verified) 94.188.205.174 Juilfs Trucking Proprietorship 709 S Geneva St., P.O. Box 252 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Terry Juilfs sarah_burke7274@hotmail.com Pomeroy IA United States Lorie Gerdes Kerstin Lyon Signed (1) The employer does not elect the employers’ liability coverage. Terry Juilfs sarah_burke7274@hotmail.com Myself Pomeroy IA United States Lorie Gerdes Kerstin Lyon 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
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
511 2021-05-10 17:53 Anonymous (not verified) 173.24.231.27 QSC Snow Removal Proprietorship 1211 Carroll Boone IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-10 Vincent A Kaylor phenox32@gmail.com Boone IA United States Lori Harvey Doug Robertson Signed (1) The employer does not elect the employers’ liability coverage. Vincent A Kaylor phenox32@gmail.com self Boone IA United States Lori Harvey Doug Robertson Signed
1671 2023-06-01 11:17 Anonymous (not verified) 94.188.205.166 Edwin Kime Proprietorship 2920 Windsor av sumner iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 edwin kime edwinkime01@gmail.com sumner ia United States Lori Ann kime Kiley Nicole kime Signed (1) The employer does not elect the employers’ liability coverage. edwin kime edwinkime01@gmail.com Same sumner ia United States Lori Ann kime Kiley nicolevkime Signed
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
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
819 2022-01-02 11:39 Anonymous (not verified) 184.94.130.66 derek verhelst trucking inc Proprietorship 1579 270th avenue canby mn 56220 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-02 derek verhelst derekvtinc@gmail.com canby yellow medicine mn lois verhelst dylan nelson Signed (1) The employer does not elect the employers’ liability coverage. derek verhelst derekvtinc@gmail.com owner canby yellow medicine mn lois verhelst dylan nelson Signed
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
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
1207 2022-07-15 10:02 Anonymous (not verified) 75.89.78.50 A&J Remodeling LLC Limited Liability Company 2 Bungalow Ct Newton, Iowa 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-15 Austin Hudson ahudson7536@gmail.com Newton Jasper IA Liz Allen Dustin Ingram Signed (1) The employer does not elect the employers’ liability coverage. Austin Hudson anjremodel@gmail.com Co-owner Newton Jasper IA Liz Allen Dustin Ingram Signed
1430 2023-01-25 14:50 Anonymous (not verified) 104.222.82.50 Pille Ceramic Tile Proprietorship 17645 Guthrie Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-25 Bernie Pille blpille@yahoo.com Maple River Carroll IA Lisa Pille None Signed (1) The employer does not elect the employers’ liability coverage. Bernie Pille blpille@yahoo.com Self Maple River Carroll IA Lisa Pille Cameron Pille Signed
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
2003 2024-01-28 12:38 Anonymous (not verified) 94.188.205.169 Wasabi Urbandale LLC Limited Liability Company 2301 Rocklyn Dr, Urbandale IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-01 Jay Wang jaywang@wasabidsm.com Clive Dallas IA Ajdin Nadarich Jeremy Boysen Signed (1) The employer does not elect the employers’ liability coverage. Jay Wang jaywang@wasabidsm.com Self Clive Dallas IA Lisa Lee Yingna Zheng Signed
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
580 2021-07-22 10:40 Anonymous (not verified) 72.13.27.253 Gudenkauf Tiling & Excavating LLC Limited Liability Company 1840 275th St 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. 2021-07-22 Terry Thomas Gudenkauf tlgudenkauf@yousq.net Manchester Delaware IA Lisa Gudenkauf Brandon Mather Signed (1) The employer does not elect the employers’ liability coverage. Terry Gudenkauf tlgudenkauf@yousq.net Owner MAnchester IA United States Lisa Gudenkauf Brandon Mather Signed
1049 2022-04-14 14:29 Anonymous (not verified) 72.13.27.253 Gudenkauf Underground llc Limited Liability Company 1840 275th St 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. 2022-04-14 Terry Gudenkauf tgudenkauf@yousq.net Manchester IA United States Lisa Gudenkauf Tim Gudenkauf Signed (1) The employer does not elect the employers’ liability coverage. Terry Gudenkauf tgudenkauf@yousq.net Self Manchester IA United States Lisa Gudenkauf Tim Gudenkauf 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
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
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
1774 2023-08-03 08:40 Anonymous (not verified) 94.188.205.168 J P Trucking, Inc. Proprietorship 8768 White Tail Lane, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-03 Jamison Noel jptrucking.jamison@gmail.com Dubuque DBQ Iowa Lindsay Noel Andy Kemp Signed (1) The employer does not elect the employers’ liability coverage. Jamison Noel jptrucking.jamison@gmail.com Owner Dubuque Dubuque Iowa Lindsay Noel Andy Kemp Signed
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
778 2021-12-05 11:39 Anonymous (not verified) 71.34.165.66 Perfection heating and Plumbing LLC Limited Liability Company 2522 3 Ave SW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-05 Edward William cooper ecooper@amermech.com Altoona Polk IA Lindsay cooper Edward cooper SR Signed (1) The employer does not elect the employers’ liability coverage. Eddie Cooper ecooper@amermech.com Self Altoona Polk IA Lindsay cooper Edward cooper SR Signed
2005 2024-01-29 08:50 Anonymous (not verified) 94.188.207.226 Laser Line Striping Proprietorship 10572 320th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-29 Dean Weikert d.lineuponline@yahoo.com Ackley Iowa United States Linda Weikert Ca Signed (1) The employer does not elect the employers’ liability coverage. Kain Helmke d.lineuponline@yahoo.com D.lineuponline@yahoo.com Ackley Butler Iowa Linda Weikert Kain Helmke Signed
1815 2023-08-23 14:16 Anonymous (not verified) 94.188.207.228 JP Distribution, LLC Limited Liability Company 3738 Pine Rdg NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-23 Jared Prelle jpdist2014@gmail.com North Liberty IA United States Linda Stien Dawn Franck Signed (1) The employer does not elect the employers’ liability coverage. Jared Prelle jpdist2014@gmail.com Owner North Liberty Johnson IA Linda Stien Dawn Franck Signed
1747 2023-07-14 12:18 Anonymous (not verified) 94.188.207.224 WIL-EQUIPMENT Limited Liability Company 16400 Highway 92 Indianola Iowa 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-14 Brian Wilson wileq@outlook.com Indianola Warren Iowa Linda Jill Wilson Megan Elizabeth Wilson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Brian Wilson wileq@outlook.com Owner of Business Indianola Iowa United States Linda Jill Wilson Megan Elizabeth Wilson Signed
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
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
2004 2024-01-28 12:41 Anonymous (not verified) 94.188.205.174 Wasabi Urbandale LLC Limited Liability Company 5106 155th Street, 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. 2024-01-28 Yean Ching Sue soamie@hotmail.com Urbandale Dallas Iowa Lina Zheng Jenna Yu Signed (1) The employer does not elect the employers’ liability coverage. Yean Ching Sue soamie@hotmail.com Owner Urbandale Dallas Iowa Lina Zheng Jenna Yu Signed
504 2021-05-06 15:43 Anonymous (not verified) 75.162.84.34 Erreguin Labra Roofing LLC Limited Liability Company 642 S Washington Ave Mason City IA 50401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-06 Hilario Labra Trejo erreguin06@gmail.com mason city cerro gordo Iowa Liliana Sanchez Yolanda Mendoza Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Fernando Erreguin Erreguin06@gmail.com member Mason city cerro gordo iowa Liliana sanchez yolanda mendoza Signed
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
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
1213 2022-07-19 14:00 Anonymous (not verified) 198.14.220.143 VLG Build & Remodle LLC Limited Liability Partnership 45547 State HWY 14 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. 2022-07-19 Vladimir Golosinskiy VLGCONSTRUCTION@YAHOO.COM Chariton IA United States Vladimir Golosinskiy Vladimir Golosinskiy Signed (1) The employer does not elect the employers’ liability coverage. LILIA GOLOSINSKIY VLGCONSTRUCTION@YAHOO.COM Wife CHARITON Iowa United States LILIA GOLOSINSKIY LILIA GOLOSINSKIY 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
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
1735 2023-07-11 08:28 Anonymous (not verified) 94.188.207.229 LBN LLC Limited Liability Company 1930 se 14th Des Moines Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Gary Fatino fatinomarketinggroup@yahoo.com Des Moines polk Iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Gary Fatino fatinomarketinggroup@yahoo.com owner des moines polk iowa liana fatino gary fatino Signed
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
1737 2023-07-11 08:32 Anonymous (not verified) 94.188.207.223 Scornos waukee llc Limited Liability Company 286 w hickman rd waukee iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Gary Fatino fatinomarketinggroup@yahoo.com des moines polk iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Gary Fatino fatinomarketinggroup@yahoo.com owner des moines polk iowa Liana Fatino Gary Fatino Signed
2104 2024-03-18 12:36 Anonymous (not verified) 94.188.205.167 Scornoos 1973 INC Proprietorship 8561 hickman rd urbandale iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-18 Gary Fatino lfatino@yahoo.com des moines Polk iowa Liana Fatino LISA VACCO Signed (1) The employer does not elect the employers’ liability coverage. Liana Fatino lfatino@yahoo.com wife des moines polk iowa Liana Fatino Lisa vacco Signed
2106 2024-03-18 12:47 Anonymous (not verified) 94.188.205.167 Scornos Altoona LLC Proprietorship 2437 adventureland dr altoona iowaa 50009 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-18 Gary Fatino lfatino@yahoo.com des moines POLK IOWA Liana Fatino LISA VACCO Signed (1) The employer does not elect the employers’ liability coverage. Liana Fatino lfatino@yahoo.com wife des moines polk iowa Liana Fatino Lisa Vacco Signed
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
2078 2024-03-06 16:19 Anonymous (not verified) 94.188.207.228 Iowa's Gutter Specialist LLC Limited Liability Company 221 4th St SE Hampton Iowa 50441 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-06 Dustin Halverson dh42312695@gmail.com Hampton Iowa United States Levi Paine Amy Hayes Signed (1) The employer does not elect the employers’ liability coverage. Dustin Halverson dh42312695@gmail.com Owner Hampton Iowa United States Levi Paine Amy Hayes Signed
997 2022-03-23 06:15 Anonymous (not verified) 167.142.233.235 Betsy Harms Agency LLC Limited Liability Company 101 Sherman Ave, Ackley, IA 50601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-23 Betsy Harms bharms@phillipsstafford.com Ackley Franklin IA Levi Harms Patricia Harms Signed (1) The employer does not elect the employers’ liability coverage. Betsy Harms bharms@phillipsstafford.com Self Ackley Franklin IA Levi Harms Patricia Harms Signed
253 2020-09-09 12:27 Anonymous (not verified) 173.18.16.129 H E Drywall INC Proprietorship 200 E Lally St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-09 Eriberto Castro hedrywall82@gmail.com Des Moines Polk Iowa Lesa Reeves Jake Hibbert Signed (1) The employer does not elect the employers’ liability coverage. eriberto castro hedrywall82@gmail.com owner Des Moines Polk Iowa Lesa Reeves Jake Hibbert Signed
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
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
490 2021-04-20 14:06 Anonymous (not verified) 173.18.16.129 frey construction Limited Liability Company 1388 205th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-20 Dana Frey dingaf37@yahoo.com Creston Union Iowa Lesa Reeves Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Dana Frey dingaf37@yahoo.com owner Creston Union Iowa Lesa Reeves Kelly Coluzzi Signed
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
627 2021-08-31 16:12 Anonymous (not verified) 173.18.16.129 D's Home Improvement Limited Liability Company 665 27th St Des Moines IA 50312 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-31 Dustin Mitchell dustinmitchell8855@gmail.com Des Moines Polk Iowa Lesa Reeves Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Dustin Mitchell dustinmitchell8855@gmail.com Owner Des Moines Polk IA Lesa Reeves Kelly Coluzzi Signed
916 2022-02-16 09:23 Anonymous (not verified) 173.18.22.217 Cesar Ponce Proprietorship 150 Aspen Dr. Norwalk IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-16 Cesar Ponce cesarponce00@icloud.com Nowalk Warren Iowa Lesa Reeves Jennifer Lambert Signed (1) The employer does not elect the employers’ liability coverage. Cesar Ponce cesarponce00@icloud.com Owner Norwalk Warren Iowa Lesa Reeves Jennifer Lambert Signed
1021 2022-03-30 11:20 Anonymous (not verified) 173.18.22.217 Arti Concrete Limited Liability Company 6901 SE 14th St Lot #226 Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-30 Gerson David Artero arti.concrete31@gmail.com Des Moines Polk IA Lesa Reeves Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Gerson David Artero arti.concrete31@gmail.com Owner Des Moines Polk IA Lesa Reeves Erick Schuldt Signed
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
1089 2022-05-05 15:49 Anonymous (not verified) 173.18.22.217 Dave Brecht Lawn Care Limited Liability Company 5213 SE 27th St Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-05 Dave Brecht Fagenmich@gmail.com Des Moines Polk IA Lesa Reeves Mitch Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Dave Brecht Fagenmich@gmail.com Owner Des Moines Polk IA Lesa Reeves Mitch Coluzzi Signed
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
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
1205 2022-07-14 13:29 Anonymous (not verified) 173.18.22.217 Residence Electric LLC Limited Liability Company 5465 Mills Civic Pkwy #317 West Des Moines 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-14 Anthony Rivera residenceelectric@outlook.com West Des Moines Polk Iowa Lesa Reeves Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Anthony Rivera residenceelectric@outlook.com Owner West Des Moines Polk Iowa Lesa Reeves Erick Schuldt Signed
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
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
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
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
1458 2023-02-16 07:20 Anonymous (not verified) 94.188.205.167 Windsor Earth Works, dba Wells Commercial Flooring Limited Liability Company 1442 73rd Street, 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. 2023-02-16 Timothy E Wells wellsba1@msn.com Windsor Heights Polk Iowa Leonard Klug Barbara Wells Signed (1) The employer does not elect the employers’ liability coverage. Barbara Wells wellsba65@gmail.com Spouse Windsor Heights Polk Iowa Leonard Klug Timothy Wells 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
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
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
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
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
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
2063 2024-02-29 10:12 Anonymous (not verified) 94.188.205.177 Geral Lee Pattison Proprietorship 22127 Hwy 52 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-29 Geral Lee Pattison pattisonglee@gmail.com GARNAVILLO IA IA Lee Zapf Andrew Corllet Signed (1) The employer does not elect the employers’ liability coverage. Geral Lee Pattison pattisonglee@gmail.com Self GARNAVILLO IA IA Lee Zapf Andrew Corllet Signed
875 2022-01-31 11:00 Anonymous (not verified) 173.31.102.93 Jhk Construction LLC Limited Liability Company 6203 Casey Ct NE cedar Rapids Iowa 52411 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-31 Edward Charles Loehr jhkcostruction10@gmail.com Cedar Rapids Linn Iowa Leanne M Loehr Autumn G Loehr Signed (1) The employer does not elect the employers’ liability coverage. Jhk Construction LLC jhkconstruction10@gmail.com Owner Cedar Rapids Linn Iowa Leanne M Loehr Autumn G Loehr Signed
446 2021-03-23 12:39 Anonymous (not verified) 174.198.72.209 Final Finish llc Limited Liability Company 3824 12th 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. 2021-03-23 Wesley Robert Detman wesdet@gmail.com Drs Moines Polk Iowa Leah Laxton Lucas Laxton Signed (1) The employer does not elect the employers’ liability coverage. Wesley Robert Detman wesdet@gmail.com Owner Des Moines Polk Iowa Leah Laxton Lucas Laxton Signed
1684 2023-06-09 14:42 Anonymous (not verified) 94.188.207.223 Brandon Thomas Proprietorship 1119 Curtiss Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-08 Brandon K Thomas Brandon.thomas@countitalljoy.com.mx Ames IA United States Leah Churchill George Trice Signed (1) The employer does not elect the employers’ liability coverage. Brandon K Thomas Brandon.thomas@countitalljoy.com.mx Same person Ames IA United States Leah Churchill George Trice Signed
358 2021-01-12 11:35 Anonymous (not verified) 173.29.116.114 Des Moines Restorations LLC Limited Liability Company 1701 Pennsylvania Avenue, Des Moines, IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-12 Christopher Rogers chris@desmoinesrestorations.com Davenport Scott IA Lea Luquire Lisa Rubio Signed (1) The employer does not elect the employers’ liability coverage. Christopher Rogers chris@desmoinesrestorations.com Owner / Employer Davenport Scott IA Lea Luquire Lisa Rubio Signed
359 2021-01-12 11:37 Anonymous (not verified) 173.29.116.114 Quad City Restorations Limited Liability Company 1225 E River Drive, Suite 320, Davenport, IA 52803 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-12 Christopher Rogers chris@quadcityrestorations.com DAVENPORT Scott IA Lea Luquire Lisa Rubio Signed (1) The employer does not elect the employers’ liability coverage. Christopher Rogers chris@quadcityrestorations.com Owner / Employer DAVENPORT Scott IA Lea Luquire Lisa Rubio Signed
854 2022-01-24 19:59 Anonymous (not verified) 217.180.228.216 Hansen Installations Limited Liability Company 109 NW Calista Ct. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-24 Brian D Hansen bdhansen33@gmail.com Grimes IA United States Laurie Mills Jaiden Nelson Signed (1) The employer does not elect the employers’ liability coverage. Brian D Hansen bdhansen33@gmail.com Self Grimes IA United States Laurie Mills Jaiden Nelson Signed
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
1039 2022-04-11 14:33 Anonymous (not verified) 199.120.121.97 Panama Electric Proprietorship 106 S Railway Panama IA 51562 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-11 Dan Wingert danwingert@fmctc.com Panama Shelby IA Laura Wingert Sylvan Kenkel Signed (1) The employer does not elect the employers’ liability coverage. Dan Wingert danwingert@fmctc.com Self Panama Shelby IA Laura Wingert Sylvan Kenkel Signed
1093 2022-05-12 06:32 Anonymous (not verified) 50.80.25.116 Beast Construction LLC Limited Liability Company 1025 O Ave NW, Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-01 Catarino Martinez Alvarez - H&C Roofing LLC handc.rconst@outlook.com North Liberty Johnson Iowa Evelyn Lagos Edgardo Hernandez Signed (1) The employer does not elect the employers’ liability coverage. Greg Saunders Gsaunders@beastconstructioncr.com Owner Cedar Rapids Linn Iowa Laura Sturm Joanie Lacayo Signed
1937 2023-12-04 17:42 Anonymous (not verified) 94.188.205.174 Albert Schwartz Proprietorship 2250 Hwy 1 Sw Kalona, ia 52247 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-04 Albert Schwartz sageburnner100@msn.com Kalona Johnson Iowa Laura Schwartz Jackie Etheredge Signed (1) The employer does not elect the employers’ liability coverage. Albert Schwartz sageburnner100@msn.com Myself Kalona Johnson Iowa Laura Schwartz Jackie Etheredge Signed
1182 2022-07-06 13:40 Anonymous (not verified) 50.80.25.116 Beast Construction LLC Limited Liability Company 1025 O Ave NW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-11 Gilberto Vasquez (GV Construction LLC) Normambazquez@gmail.com Iowa City IA United States Pedro Pinto Rafael Garcia Signed (1) The employer does not elect the employers’ liability coverage. Greg Saunders gsaunders@beastconstructioncr.com Owner CEDAR RAPIDS IA United States Laura Saunders Joanie Lacayo Signed
1160 2022-06-20 10:08 Anonymous (not verified) 138.43.237.249 High Caliber Fiber Limited Liability Company 2958 110th ave masonville IA, 50654 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-20 chris cooper Chris_cooper@highcaliberfiber.com Masonville Delaware IA Laura Rose Lentz Blake Dean Elbert Signed (1) The employer does not elect the employers’ liability coverage. Chris Cooper Chris_cooper@highcaliberfiber.com self Masonville Delaware IA Laura Rose Lentz BLake Dean Elbert Signed
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
658 2021-09-27 14:01 Anonymous (not verified) 167.142.136.87 Crosser Electric, Inc Partnership PoBox 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 Victoria Halvorsen vhalvorsen@aol.com Eldora Hardin Iowa Laura Kramer Melissa Sison Signed (1) The employer does not elect the employers’ liability coverage. Victoria or Vicki Halvorsen vhalvorsen@aol.com Partner sec/treasure Eldora Hardin Iowa Laura Kramer Melissa Sison Signed
196 2020-06-30 23:17 Anonymous (not verified) 72.46.186.211 Artie's Construction Proprietorship 520 5th Ave Sibley, IA 51249 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-30 Gloria Esther Torres torrglo@hotmail.com Sibley Osceola Iowa Laura Barrie Morgen Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Gloria Esther Torres torrglo@hotmail.com Self Sibley Osceola Iowa Laura Barrie Morgen Gonzalez Signed
2182 2024-04-25 19:37 Anonymous (not verified) 94.188.205.174 Curtis Bunnell sub contractor Proprietorship 907 s main st sigourney IA 52591 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-23 CURTIS BUNNELL curt3551.cb@gmail.com Sigourney Keokuk IA Latisha Bunnell Wendy Yeo Signed (1) The employer does not elect the employers’ liability coverage. Curtis bunnell curt3551.cb@gmail.com Same person Sigourney Keokuk IA Latisha bunnell Wendy Yeo Signed
267 2020-09-22 07:04 Anonymous (not verified) 74.84.65.174 Angel Jesus Argueta Proprietorship 1523 Arlington Ave Des Moines, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-22 Angel Jesus Argueta Juanargueta22@yahoo.com Des Moines Polk Iowa Larry Eugene Guire Eric Michael West Signed (1) The employer does not elect the employers’ liability coverage. Angel Jesus Argueta Juanargueta22@yahoo.com Same Des Moines Polk Iowa Larry Eugene Guire Eric Michael West Signed
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
447 2021-03-24 14:09 Anonymous (not verified) 208.90.15.53 Gabe Saenz, LLC Limited Liability Company PO Box 53 Humboldt, IA 50548 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-24 Gabriel Saenz gsaenzh@gmail.com Humboldt Humboldt Iowa Lance DeWinter Cathy Schipull Signed (1) The employer does not elect the employers’ liability coverage. Gabriel Saenz gsaenzh@gmail.com Owner Humboldt Humboldt Iowa Lance DeWinter Cathy Schipull Signed
200 2020-07-09 10:56 Anonymous (not verified) 167.142.98.40 brian chisum Proprietorship 168 c.r. 2007 valley view tx I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 brian chisum chisum413@gmail.com valley view cooke tx lakota larson john morland Signed (1) The employer does not elect the employers’ liability coverage. brian chisum chisum413@gmail.com self valley view cooke tx lakota larson john morland Signed
201 2020-07-09 11:07 Anonymous (not verified) 167.142.98.40 Brock Chisum Proprietorship 369 Wise Rd., Decatur, TX76234 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Brock Chisum bchisum@hotmail.com Decatur, TX Wise Texas Lakota Larson Ryan Stott Signed (1) The employer does not elect the employers’ liability coverage. Brock Chisum bchisum@hotmail.com Self Decatur Wise Texas Lakota Larson Ryan Stott Signed
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
857 2022-01-26 16:27 Anonymous (not verified) 207.199.212.86 Grahm's Tree Service Proprietorship 406 2nd Ave Charles City, IA 50616 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-22 Graham Kuethe lacy@cioia.com Charles City Floyd Iowa Lacy Carolan Tony Trower Signed (1) The employer does not elect the employers’ liability coverage. Graham Kuethe lacy@cioia.com Owner Charles City Floyd Iowa Lacy Carolan Tony Trower Signed
2093 2024-03-13 15:53 Anonymous (not verified) 94.188.205.176 Tony Deutmeyer Limited Liability Company PO BOX 152 HIAWATHA IA 52233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-13 Anthony John Deutmeyer tonydeutmeyer@gmail.com Hiawatha Linn Iowa Lacey riley Andrew prochaska Signed (1) The employer does not elect the employers’ liability coverage. Anthony Deutmeyer tonydeutmeyer@gmail.com Self Hiawatha Linn Iowa Lacey riley Andrew prochaska Signed
132 2020-04-27 17:26 Anonymous (not verified) 73.94.97.93 Kota Construction Limited Liability Company 52 SE Pembrooke Ln I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-27 Dakota Beaulieu cody.b@buildwithkota.com Waukee IA United States Kyli Torkelson Koray Furrow Signed (1) The employer does not elect the employers’ liability coverage. Dakota Beaulieu cody.b@buildwithkota.com Self Waukee Dallas Iowa Kyli Torkelson Koray Furrow Signed
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
1871 2023-10-18 10:27 Anonymous (not verified) 94.188.205.169 Derik Gonyier Proprietorship 1421 Chicago Ave, Savanna, IL 61074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-14 Derik Ray Gonyier deriknalexis121413@gmail.com Savanna Carroll IL Kyle Lee Sturtz Daryl Gonyier Signed (1) The employer does not elect the employers’ liability coverage. Derik Ray Gonyier deriknalexis121413@gmail.com Self Savanna Carroll IL Kylee Lee Daryl Eugene Gonyier Signed
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
67 2020-02-19 10:16 Anonymous (not verified) 198.167.182.164 AWF579 LLC Limited Liability Company 13 Lynden Dr NE, Iowa City, IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-18 Jeffrey Schiltz jeffschiltz2@yahoo.com Iowa City Johnson Iowa Kyle Stahle Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Schiltz jeffschiltz2@yahoo.com Managing Member Iowa City Johnson Iowa Kyle Stahle Dyan Kriener Signed
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
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
1375 2022-11-18 10:21 Anonymous (not verified) 166.181.87.119 Heff Built Construction LLC Limited Liability Company 1403 Kodiak Dr NW Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-18 Jacob Heffernen jheffernen@gmail.com Cedar Rapids Linn IA Kyle Reid Amanda Frese Signed (1) The employer does not elect the employers’ liability coverage. Jacob Heffernen jheffernen@gmail.com N/A Cedar Rapids Linn IA Kyle Reid Amanda Frese Signed
1376 2022-11-18 10:22 Anonymous (not verified) 166.181.87.119 Ashley Heffernen Proprietorship 4009 Majestic Ct NE Cedar Rapids Iowa 52411 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-18 Ashley Rae Heffernen ashley.heffernen@gmail.com Cedar Rapids Linn Iowa Kyle Reid Amanda Frese Signed (1) The employer does not elect the employers’ liability coverage. Ashley Rae Heffernen ashley.heffernen@gmail.com Self Cedar Rapids Linn Iowa Kyle Reid Amanda Frese Signed
1872 2023-10-18 10:59 Anonymous (not verified) 94.188.205.177 Derik Gonyier Proprietorship 1421 Chicago Ave, Savanna, IL 61074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-14 Derik Ray Gonyier deriknalexis121413@gmail.com Savanna Carroll IL Kyle Lee Sturtz Daryl Eugene Gonyier Signed (1) The employer does not elect the employers’ liability coverage. Derik Ray Gonyier deriknalexis121413@gmail.com Self Savanna Carroll IL Kyle Lee Sturtz Daryl Eugene Gonyier Signed
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
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
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
1390 2022-12-12 10:27 Anonymous (not verified) 97.125.170.79 Norwalk Cleaning Servicesw Limited Liability Company 520 W High Rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-12 Jacob Hibbert Maryhib@icloud.com Norwalk IA United States Kyle Grandstaff Nicole Nichols Signed (1) The employer does not elect the employers’ liability coverage. Jacob Hibbert maryhib@icloud.com Self Norwalk Warren United States Kyle Grandstaff Nicole Nichols Signed
2046 2024-02-15 11:29 Anonymous (not verified) 94.188.205.175 Ervin Cabrera Mendez Proprietorship 4822 Meadowlark Lane, Sioux City, Iowa 51106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-01 Ervin Cabrera Mendez ervincabrera89@gmail.com Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed (1) The employer does not elect the employers’ liability coverage. Ervin Cabrera Mendez ervincabrera89@gmail.com Owner Sioux City Woodbury Iowa Kyle Buum David Jacobs Signed
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
234 2020-08-18 09:13 Anonymous (not verified) 67.55.224.208 Anthony Keahi dba Hawaiian Handyman Proprietorship 928 8th Ave SE, Sioux Center, IA 51250-2502 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-17 Anthony Keahi hhkeahi@gmail.com Sioux Center Sioux Iowa Kyle Blankers Julia Huisman Signed (1) The employer does not elect the employers’ liability coverage. Anthony Keahi hhkeahi@gmail.com Self - sole proprietorship Sioux Center Sioux Iowa Kyle Blankers Julia Huisman Signed
1379 2022-11-22 11:44 Anonymous (not verified) 166.181.89.236 365 Services LLC Limited Liability Company 306 hayes st e hazleton iowa 50641 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-22 Clayton marshall davis Lcrc365@outlook.com Hazleton Bucanan Iowa Grace lilibridge Kurt king Signed (1) The employer does not elect the employers’ liability coverage. Clayton marshall davis Lcrc365@outlook.com Owner Hazleton Bucanan Iowa Kurt kind Grace lilibridge Signed
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
456 2021-04-02 10:02 Anonymous (not verified) 207.177.7.191 Goettsch Dispatch Inc Limited Liability Company 200 Main St Galva, IA 51020 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-15 Andrew Goettsch andygoettsch@gmail.com Galva Ida Iowa Kristy Dewey Terri Ullrich Signed (1) The employer does not elect the employers’ liability coverage. Andrew Goettsch andygoettsch@gmail.com President Galva Ida Iowa Kristy Dewey Terri Ullrich Signed
1091 2022-05-06 09:54 Anonymous (not verified) 97.127.228.168 American Concrete Proprietorship 2629 Sheffield dr. Davenport iowa 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Craig wells craiglwells@hotmail.com Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed (1) The employer does not elect the employers’ liability coverage. DK home products anne@dkhomeproducts.com Sub contractor Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed
313 2020-11-11 20:35 Anonymous (not verified) 174.198.78.148 Wilson Snow Maintenance Proprietorship 3518 183rd Avenue, Carlisle, Iowa 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-11 Bruce E. Wilson bewilson83@gmail.com Carlisle Warren Iowa Kristen Wilson Garett Wilson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Bruce Wilson bewilson83@gmail.com self Carlisle Warren Iowa Kristen Wilson Garett Wilson Signed
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
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
237 2020-08-18 19:01 Anonymous (not verified) 174.125.150.45 Wdflyers llc Limited Liability Company 453 hwy 1183 Simmesport la 71369 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-25 Donald Anderson sugarscoot@yahoo.com Simmesport Avoyelles Louisiana kolter coco wendy coco Signed (1) The employer does not elect the employers’ liability coverage. Donald Anderson sugarscoot@yahoo.com self Simmesport Avoyelles Louisiana kolter coco wendy coco Signed
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
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
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
1873 2023-10-20 09:25 Anonymous (not verified) 94.188.207.228 GC Hauling LLC Limited Liability Company 310 North 18th Street, Indianola, IA, 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-20 Garrett Joseph Claerhout gjclaerhout@hotmail.com INDIANOLA IA IA Kirsten Claerhout Jay Claerhout Signed (1) The employer does not elect the employers’ liability coverage. Garrett Joseph Claerhout gjclaerhout@hotmail.com Same Person INDIANOLA IA IA Kirsten Claerhout Jay Claerhout Signed
1636 2023-05-10 07:31 Anonymous (not verified) 94.188.205.167 Brad Bower Drywall LLC Limited Liability Company 209 Northridge West Branch, IA 52358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-10 Bradley Bower bbower74@gmail.com West Branch Cedar Iowa Kirk Strunk Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Brad Bower bbower74@gmail.com Self West Branch Cedar Iowa Kirk Strunk Chris Hay Signed
1392 2022-12-12 11:55 Anonymous (not verified) 173.215.8.119 Jones OD PLLC Limited Liability Company 17792 538th St Griswold, IA 51535 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-08 Travis Preston Jones jonesodpllc@gmail.com Griswold Pottawattamie Iowa Kirk Douglas Lantz Karla Kay Lantz Signed (1) The employer does not elect the employers’ liability coverage. Travis Preston Jones jonesodpllc@gmail.com Officer Griswold Pottawattamie Iowa Kirk Douglas Lantz Karla Kay Lantz Signed
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
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
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
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
972 2022-03-14 18:01 Anonymous (not verified) 207.32.37.48 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan, IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-14 Abby Glendenning lanceandabby@wccta.net Churdan Greene Iowa Kim Kersey Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Kim Kersey Shelly Brus Signed
973 2022-03-14 18:02 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 Terry 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
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
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
839 2022-01-14 10:56 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 Tyler Billmeyer tbillmeyer@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
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
1480 2023-02-24 08:54 Anonymous (not verified) 94.188.205.176 Shear Texture Limited Liability Company 2000 Wiley 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. 2023-02-24 Wendy Kiser kiser187@msn.com Cedar Rapids Linn Iowa Kim Erickson Shauna Whitaker Signed (1) The employer does not elect the employers’ liability coverage. Wendy Kiser kiser187@msn.com Self Cedar Rapids Linn Iowa Kim Erickson Shauna Whitaker Signed
2087 2024-03-11 09:39 Anonymous (not verified) 94.188.205.175 Shear Texture Limited Liability Company 2000 Wiley 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. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-03-11 Wendy Kiser kiser187@msn.com Cedar Rapids Linn Iowa Kim Erickson Shauna Whitaker Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Wendy Kiser kiser187@msn.com Self Cedar Rapids Linn Iowa Kim Erickson Shauna Whitaker 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
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
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
1281 2022-08-24 11:06 Anonymous (not verified) 47.185.154.197 Zachary Bobo Proprietorship 2116 Newport Dr. Flower Mound, Tx. 75028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Zachary Bobo ryan.zac@yahoo.com Flower Mound Denton Texas Kieth Volquardsen Chris Ventimiglia Signed (1) The employer does not elect the employers’ liability coverage. Zachary Bobo ryan.zac@yahoo.com Self Flower Mound Denton Texas Kieth Volquardsen Chris Ventimiglia 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
1410 2023-01-06 10:58 Anonymous (not verified) 173.25.103.95 Bryce Kenworthy Proprietorship 155 NW Maple St Elkhart IA 50073 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-06 Bryce Kenworthy midwest.fencingandconstruction@gmail.com Elkhart Polk Iowa Kevin Corn Nicole Almburg Signed (1) The employer does not elect the employers’ liability coverage. Bryce Kenworthy midwest.fencingandconstruction@gmail.com Owner Elkhart Polk Iowa Kevin Corn Nicole Almburg Signed
730 2021-11-08 14:58 Anonymous (not verified) 97.64.139.42 JZ INC Limited Liability Company 2509 Ne 10th CT Grimes Iowa 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-08 James Zastrow Zastrow74@gmail.com Grimes Iowa United States Kevan Wiggins Jeremy Holmes Signed (1) The employer does not elect the employers’ liability coverage. James Zastrow zastrow74@gmail.com Self grimes polk iowa Kevan Wiggins Jeremy Holmes Signed
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
2067 2024-02-29 16:58 Anonymous (not verified) 94.188.205.166 James Baker Limited Liability Company 1510 E 1st Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-01 James Baker jaykeribaker@yahoo.com Indianola Warren IA Keri Baker Brenan Baker Signed (1) The employer does not elect the employers’ liability coverage. James Baker jaykeribaker@yahoo.com Self Indianola Warren IA Keri Baker Brenan Baker Signed
1199 2022-07-11 16:28 Anonymous (not verified) 166.222.225.181 Myriad Global Business Solutions Proprietorship 8016 Brooks Loop I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 James Eugene Hasquet, III Jay.Hasquet@Outlook.com Spearfish South Dakota United States Kent Orfield Kyle Padget Signed (1) The employer does not elect the employers’ liability coverage. James Eugene Hasquet, III Jay.Hasquet@Outlook.com Self Spearfish South Dakota United States Kent Orfield Kyle Padget Signed
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
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
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
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
1570 2023-04-12 18:09 Anonymous (not verified) 94.188.205.166 Staley Engineering Consultants, LLC Limited Liability Company 4212 Holland Drive, Des Moines, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-12 Donald K Staley Don.Staley@q.com Des Moines Iowa United States Kendall S. Staley Gary D. Hlavka Signed (1) The employer does not elect the employers’ liability coverage. Donald K Staley Don.Staley@q.com Owner Des Moines Iowa United States Kendall S. Staley Gary D. Hlavka Signed
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
684 2021-10-20 13:25 Anonymous (not verified) 65.144.174.26 A and H Home Improvement Limited Liability Company 600 NE 64th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-20 Ivan A. Abel aandhhomeimprovement@gmail.com Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed (1) The employer does not elect the employers’ liability coverage. Ivan A. Abel aandhhomeimprovement@gmail.com Self Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed
2025 2024-02-06 20:49 Anonymous (not verified) 94.188.207.223 Blue Dog Stump Grinding Limited Liability Company 32199 Sumac Road Neola IA 51559 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-06 Zebulan bluedogstumpgrinding@gmail.com Neola Pottowattamie Iowa Kelsey Wahle Mike Stamp Signed (1) The employer does not elect the employers’ liability coverage. Zebulan Wahle bluedogstumpgrinding@gmail.com Owner Neola Pottowattomie Iowa Kelsey Wahle Mike Stamp Signed
2041 2024-02-12 10:37 Anonymous (not verified) 94.188.207.230 Blue Dog Stump Grinding LLC Limited Liability Company 32199 Sumac Rd Neola, IA 51559 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-12 Zebulan Kent Wahle bluedogstumpgrinding@gmail.com Neola Pottawattamie Iowa Kelsey Wahle Michael Stamp Signed (1) The employer does not elect the employers’ liability coverage. Zebulan Kent Wahle bluedogstumpgrinding@gmail.com Self Neola Pottawattamie Iowa Kelsey Wahle Michael Stamp Signed
1919 2023-11-21 14:11 Anonymous (not verified) 94.188.207.227 Refined Construction Limited Liability Company 4148 Mattern ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-21 Dustin Martin dudtin.martin106@gmail.com Des Moines Polk IA Kelsey Baldinelli Brandi Martin Signed (1) The employer does not elect the employers’ liability coverage. Dustin Martin dustin.martin106@gmail.com Sole officer Des Moines Polk IA Kelsey Baldinelli Brandi Martin Signed
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
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
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
184 2020-06-12 10:38 Anonymous (not verified) 174.243.112.246 brian kass Proprietorship 15064 kass road I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-11 brian kass kass5kass@hotmail.com dubuque Iowa Iowa kelly kass jenny McIntyre Signed (1) The employer does not elect the employers’ liability coverage. brian kass kass5kass@hotmail.com self dubuque Iowa iowa Kelly Kass Jenny McIntyre Signed
1798 2023-08-14 12:16 Anonymous (not verified) 94.188.207.223 David Robles Proprietorship 3912 E 23rd St Des Moines, Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-09 David Robles deb@piciowa.com Des Moines Polk Iowa Debra E Stratton Kelly K Denger Signed (1) The employer does not elect the employers’ liability coverage. David Robles deb@piciowa.com self Des Moines Polk Iowa Kelly K Denger Debra E Stratton Signed
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
1692 2023-06-15 15:20 Anonymous (not verified) 94.188.207.228 Javier Rodriguez Proprietorship 1512 18th St Des Moines, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-14 Javier A Rodriguez R.Javier14@gmail.com Des Moines Polk Iowa Kelly Denger Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. Javier A Rodriguez R.Javier14@gmail.com self Des Moines Polk Iowa Kelly Denger Debra Stratton Signed
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
194 2020-06-24 15:24 Anonymous (not verified) 173.16.140.254 Eugene Behle Proprietorship 3134 6th Ave Des Moines IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-24 Eugene Behle III Bub4bme@gmail.com Des Moines Polk Iowa Kelly Coluzzi Mitch Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Eugene Behle III Bub4bme@gmail.com Self Des Moines POLK Iowa Kelly Coluzzi Mitch Coluzzi Signed
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
1359 2022-11-04 10:48 Anonymous (not verified) 173.18.22.217 Lewis Enterprises Limited Liability Company 2723 Witmer Street Des Moines Ia 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-04 Corey Lewis coreyboy1990@gmail.com Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Corey Lewis coreyboy1990@gmail.com Owner Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed
1490 2023-03-03 10:31 Anonymous (not verified) 94.188.205.175 Bagby Lawncar and More Limited Liability Company 921 Pleasant Street, Des Moines IA 50309 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-03 Cory Michael Bagby bagbylawncareandmore@gmail.com 921 Pleasant Street Polk Iowa Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Cory Bagby babylawncareandmore@gmail.com Owner Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed
1823 2023-08-29 12:46 Anonymous (not verified) 94.188.205.177 A&S Construction LLC Proprietorship 5920 Village Circle Johnston IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-28 Admir Omerovic sabinamur22@icloud.com 5920 Village Circle Polk IA Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Admir Omerovic sabinamu22@icloud.com Owner Johnston Polk IA Kelly Coluzzi Erick Schuldt Signed
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
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
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
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
1528 2023-03-22 10:37 Anonymous (not verified) 94.188.205.175 Uhl Cattle Company Partnership 3329 Ozark Ave, Mapleton IA 51034 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Tonya Jean Uhl tonyajuhl@gmail.com Mapleton Woodbury iowa Keaten Anthony Miller Erik Michael Boyle Signed (1) The employer does not elect the employers’ liability coverage. Tonya Jean Uhl tonyajuhl@gmail.com Owner Mapleton Woodbury Iowa Keaten Anthony Miller Erik Michael Boyle Signed
1529 2023-03-22 10:40 Anonymous (not verified) 94.188.205.175 Uhl Cattle Company Partnership 3329 Ozark Ave, Mapleton IA 51034 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Troy Michael Uhl troyuhl1224@gmail.com Mapleton Woodbury Iowa Keaten Anthony Miller Erik Michael Boyle Signed (1) The employer does not elect the employers’ liability coverage. Tonya Jean Uhl tonyajuhl@gmail.com Brother Mapleton Woodbury Iowa Keaten Anthony Miller Erik Michael Boyle 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
320 2020-11-17 10:08 Anonymous (not verified) 65.103.82.36 Brian Behnkendorf dba Dutchmen Services Proprietorship 55 Rose Court West, Geneseo IL 61254 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-13 Brian Behnkendorf 4gbbehnk@gmail.com Geneseo Henry Illinois Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. Brian Behnkendorf 4gbbehnk@gmail.com Self Geneseo Henry Illinois Kayla Artioli Eric Johnson Signed
289 2020-10-23 14:42 Anonymous (not verified) 65.103.82.36 Go Green Lawn and Tree Proprietorship 2911 N Harrison st Davenport IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-23 Brandon gogreenlawnandtree@yahoo.com davenport scott iowa Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. brandon gordon gogreenlawnandtree@yahoo.com self davenport scott ia kayla eric Signed
333 2020-12-05 08:57 Anonymous (not verified) 173.25.143.97 Groen Pediatric Consulting Limited Liability Company 1206 NE 31ST ST Ankeny, IA 50021 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-01 Amy Groen dramygroen@yahoo.com Ankeny Iowa United States Daniel Martin Anita Anderson Signed (1) The employer does not elect the employers’ liability coverage. Amy Groen dramygroen@yahoo.com self Ankeny Iowa United States Kay Martin Priscilla Putzier Signed
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
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
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
1730 2023-07-09 23:39 Anonymous (not verified) 94.188.207.225 Steffens Constuction Proprietorship 68222 Lansing Road, Wiota, IA 50274 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-07 Bradyn Richard Steffens steffens4211@gmail.com Wiota Cass Iowa Katrina Sonntag Chris Obrien Signed (1) The employer does not elect the employers’ liability coverage. Audra Kelley Steffens steffens4211@gmail.com wife Wiota Cass Iowa Katrina Sonntag Chris Obrien Signed
1664 2023-05-25 13:18 Anonymous (not verified) 94.188.207.227 Jason Vreeman Proprietorship 5571 170th St sibley Ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-25 Jason Vreeman jvreeman21@gmail.com Sibley Osceola IA Katie Vreeman Jerry vreeman Signed (1) The employer does not elect the employers’ liability coverage. Jason Vreeman jvreeman21@gmail.com Self Sibley Osceola IA Katie Vreeman Jerry vreeman Signed
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
386 2021-02-08 12:10 Anonymous (not verified) 192.30.185.142 CS Iron Design Proprietorship 311 Powells Addition, Crescent, IA 51526 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-08 Christopher Stoffel ctstoffel@gmail.com Crescent Pottawattamie IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Christopher Stoffel ctstoffel@gmail.com Owner Crescent Pottawattamie IA Katie Jenks Nate Blaeser Signed
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
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
399 2021-02-15 14:44 Anonymous (not verified) 192.30.185.142 Poss Concrete Proprietorship 3106 Dodge Ave, Sioux City, IA 51106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-15 Corey Poss coreyposs1@gmail.com Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Corey Poss coreyposs1@gmail.com Owner Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed
400 2021-02-15 14:44 Anonymous (not verified) 192.30.185.142 Certified Radon Mitigation Proprietorship 4304 Garretson Ave, Sioux City, IA 51106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-15 Erik Poss rn222@outlook.com Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Erik Poss rn222@outlook.com Owner Sioux City Woodbury IA Katie Jenks Nate Blaeser Signed
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
430 2021-03-10 13:01 Anonymous (not verified) 192.30.185.142 Trey LaGois Construction Proprietorship 132 W Cedar St, Hinton, IA 51024 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Trey LaGois treylagois2015@gmail.com Hinton Plymouth IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Trey LaGois treylagois2015@gmail.com Owner Hinton Plymouth IA Katie Jenks Nate Blaeser Signed
435 2021-03-15 15:09 Anonymous (not verified) 192.30.185.142 Marx Construction Proprietorship 33044 484th Ave, Jefferson, SD 57038 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Tony Marx tmarx416@hotmail.com Jefferson Union SD Katie Jenks Virginia Anderson Signed (1) The employer does not elect the employers’ liability coverage. Tony Marx tmarx416@hotmail.com Owner Jefferson Union SD Katie Jenks Virginia Anderson Signed
453 2021-03-26 08:27 Anonymous (not verified) 192.30.185.142 DYAD LLC Partnership 2308 Summit St, Sioux City, IA 51104 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-26 Andrew Glisar john@kellyconstruction.com Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed (1) The employer does not elect the employers’ liability coverage. Andrew Glisar john@kellyconstruction.com Owner/Partner Sioux City Woodbury IA Katie Jenks Jenni Ebner Signed
507 2021-05-10 10:20 Anonymous (not verified) 192.30.186.37 Stowe's Drywall Proprietorship PO Box 712, Ponca, NE 68776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-10 Danny Stowe deb.nana.stowe@gmail.com Ponca Dixon NE Katie Jenks Virginia Anderson Signed (1) The employer does not elect the employers’ liability coverage. Danny Stowe deb.nana.stowe@gmail.com Owner Ponca Dixon NE Katie Jenks Virginia Anderson Signed
1902 2023-11-10 08:45 Anonymous (not verified) 94.188.207.226 Huff Construction LLC Limited Liability Company 1309 Business 30 Sw, Mount Vernon, IA 52314 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-10 Jason Huff huff.jasonm@gmail.com Mount Vernon IA United States Katie Huff Van Huff Signed (1) The employer does not elect the employers’ liability coverage. Jason Huff huff.jasonm@gmail.com Owner Mount Vernon IA United States Katie Huff Van Huff Signed
9 2019-12-16 11:33 Anonymous (not verified) 50.81.115.85 Travis Garrett and Caleb Elliott Partnership P.O. Box 55, Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-16 Travis Garrett onethird4599@gmail.com Boone Boone IA Katie Frame Jessica Carroll Signed (1) The employer does not elect the employers’ liability coverage. Travis Garrett & Caleb Elliott onethird4599@gmail.com Owner Boone Boone IA Katie Frame Jessica Carroll Signed
10 2019-12-16 11:35 Anonymous (not verified) 50.81.115.85 Travis Garrett and Caleb Elliott Partnership P.O. Box 55, Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-16 Caleb Elliott onethird4599@gmail.com Boone Boone IA Katie Frame Jessica Carroll Signed (1) The employer does not elect the employers’ liability coverage. Travis Garrett & Caleb Elliott onethird4599@gmail.com Owner Boone Boone IA Katie Frame Jessica Carroll Signed
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
1398 2022-12-21 22:02 Anonymous (not verified) 24.149.20.131 B's Lawn Care Limited Liability Company 1118 Rainbow Drive, Cedar Falls, Iowa 50613, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-21 Brandon Ballenger lawncare.bee@gmail.com Cedar Falls Iowa United States Katie Ballenger Tyler Ballenger Signed (1) The employer does not elect the employers’ liability coverage. Brandon Ballenger lawncare.bee@gmail.com Owner/Operator Cedar Falls Iowa United States Katie Ballenger Tyler Ballenger Signed
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
144 2020-04-29 11:20 Anonymous (not verified) 65.158.103.107 Symbiotic Gardens LLC Limited Liability Company 3403 Dubuque Avenue Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-29 Brandon Kam symbioticgardens@gmail.com Des Moines Polk Iowa Kathy Schulte Larry Johnson Signed (1) The employer does not elect the employers’ liability coverage. Brandon Kam symbioticgardens@gmail.com same Des Moines Polk Iowa Kathy Schulte Larry Johnson Signed
502 2021-05-04 12:56 Anonymous (not verified) 75.89.78.95 HENNICK TREE SERVICE LLC Limited Liability Company 1852 MAINE RIDGE ROAD, CENTRAL CITY, IA 52214 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-05-04 BRANDON ALAN HENNICK hennicktreeservice@gmail.com CENTRAL CITY LINN IOWA KATHY RUTH WOOD ROBBIE WILLIAM WILLIS Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Brandon Hennick hennicktreeservice@gmail.com OWNER CENTRAL CITY IA United States KATHY RUTH WOOD ROBBIE WILLIAM WILLIS Signed
824 2022-01-06 20:57 Anonymous (not verified) 209.252.175.92 Rottweiler Remodel & Repair LLC Limited Liability Company 1503 10th Ave 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. 2022-01-06 Zechariah Robert DeLaVergne rottweilerremodel@gmail.com Cedar Rapids Linn County Iowa Kathy Maxine Morgan Daisha Rae Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Zechariah DeLaVergne rottweilerremodel@gmail.com Owner Cedar Rapids Linn County Iowa Kathy Maxine Morgan daisha rae gonzalez Signed