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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:
242 2020-08-24 09:27 Anonymous (not verified) 159.242.43.24 Bontreger Seamless Gutters Proprietorship 501 S Center St. Zearing Ia 50278 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-24 Harvey Bontreger borntrgerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Bontreger borntrgerharvey@gmail.com Owner Zearing Story Ia Alex G Meier Daniel Wunschel Signed
243 2020-08-24 11:31 Anonymous (not verified) 159.242.43.24 Borntreger Seamless Gutters Proprietorship 501 S Center St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-24 Harvey Borntrager Borntregerharvey@gmail.com Zearing Story Ia Alex G Meier Daniel Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Harvey Borntreger borntregerharvey@gmail.com Owner Zearing Story Ia Alex Meier Daniel Wunschel Signed
1170 2022-06-24 08:52 Anonymous (not verified) 66.255.230.24 Anderson's Flying Service Proprietorship PO Box 127 Robbins, CA 95676 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-24 Stephen Anderson steve@andersonsflying.com YUBA CITY CA United States Greg Foster Cliff Snelling Signed (1) The employer does not elect the employers’ liability coverage. Stephen Anderson steve@andersonsflying.com Self YUBA CITY CA United States Greg Foster Cliff Snelling Signed
984 2022-03-18 11:34 Anonymous (not verified) 207.177.116.48 Craig Jacoba Signs Proprietorship 20404 Walnut Street Yarmouth, IA 52660 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-18 Craig Allan Jacoba craigjacoba1@hotmail.com Yarmouth Des Moines Iowa Amy Moyner Brenda Levitt Signed (1) The employer does not elect the employers’ liability coverage. Craig Jacoba craigjacoba1@gmail.com subcontractor Yarmouth Des Moines Iowa Amy Moyner Brenda Levitt Signed
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
674 2021-10-15 09:43 Anonymous (not verified) 173.29.63.3 Peter Hawley Proprietorship 524 n galena ave, Wyoming Illinois 61491 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-15 Peter Anthony Hawley hawleypete801@gmail.com Wyoming Stark Illinois Elizabeth Doreen Hawley Ian Matthew Esmoil Signed (1) The employer does not elect the employers’ liability coverage. Peter Anthony Hawley hawleypete801@gmail.com Self Wyoming Stark IL Elizabeth Doreen Hawley Ian Matthew Esmoil Signed
70 2020-02-19 19:30 Anonymous (not verified) 173.25.39.58 Central Iowa Portable Welding Limited Liability Company 708 S Main St. Woodward Ia, 50276 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-19 Eric Lendt Eric@weldiowa.com Woodward America IA Chris Lendt Central Iowa Portable Welding Signed (1) The employer does not elect the employers’ liability coverage. Central Iowa Portable Welding Eric@weldiowa.com Himself woodward American IA Central Iowa Portable Welding Central Iowa Portable Welding Signed
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
273 2020-10-05 13:57 Anonymous (not verified) 173.30.54.139 Jackson Exteriors Proprietorship 705 Cherry Avenue Woodward,ia 50276 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-05 Lucas Jackson ljajackson41977@gmail.com Woodward IA United States Cody Roth Dustin Perry Signed (1) The employer does not elect the employers’ liability coverage. Lucas Jackson ljajackson41977@gmail.com Owner Woodward Dallas United States Cody Roth Dustin perry Signed
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
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
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
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
1157 2022-06-16 07:56 Anonymous (not verified) 97.125.185.191 Apex Remodeling Proprietorship 709 w. North St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-15 Nick Winters nick.winters@apex-roofing.com WINTERSET Iowa Iowa Erin Winters Rob Tennat Signed (1) The employer does not elect the employers’ liability coverage. Nick Winters nick.winters@apex-roofing.com Owner WINTERSET Iowa Iowa Erin Winters Rob Tennat Signed
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
694 2021-10-26 15:30 Anonymous (not verified) 65.144.174.26 Escoto Tile Proprietorship 6820 University Ave Windsor Heights, IA 50324 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-26 Salvador Escoto escototile@gmail.com Windsor Heights Polk Iowa Claudia Veronica Ojeda Escoto Josefina Escoto Signed (1) The employer does not elect the employers’ liability coverage. Salvador Escoto escototile@gmail.com Owner WINDSOR HEIGHTS Polk Iowa Claudia Veronica Ojeda Escoto Josefina Escoto Signed
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
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
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
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
1488 2023-02-28 14:04 Anonymous (not verified) 94.188.207.227 Scotts Side Work Plus Limited Liability Company 304 Wilshire Blvd Windsor Heights IA 50324 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-28 Lansing Scott scottssideworkplus@gmail.com Windsor Heights Iowa United States Collin scott Austyn Scott Signed (1) The employer does not elect the employers’ liability coverage. Lansing Scott scottssideworkplus@gmail.com owner Windsor Heights Iowa United States Austyn Scott Tracy scott Signed
17 2019-12-31 09:24 Anonymous (not verified) 72.35.186.80 Grgurich Dozing & Tiling, LLC Partnership PO Box 131, Williamson, IA 50272 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-31 Seth Grgurich mcbroomt15@gmail.com Williamson Lucas Iowa Eric Curran Stacy Smyser Signed (1) The employer does not elect the employers’ liability coverage. Seth Grgurich mcbroomt15@gmail.com Partner Williamson Lucas Iowa Eric Curran Stacy Smyser Signed
470 2021-04-13 09:34 Anonymous (not verified) 173.21.135.56 JNZ Recruiting LLC Limited Liability Company 703 Washington St. Williamsburg, IA 52361 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-04-07 Javier Nevarez amanda@burginsuranceagency.com Williamsburg IA IA Amanda Clubb Bradley Schaefer Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Javier Nevarez amanda@burginsuranceagency.com Self Williamsburg Iowa Iowa Amanda Clubb Bradley Schaefer Signed
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
1852 2023-09-24 16:02 Anonymous (not verified) 94.188.205.174 Handy Andy Enterprises LLC Limited Liability Company PO Box 479, Williamsburg, Iowa 52361 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-01 Andrew J Garner andy@handyandyenterprises.net Williamsburg Iowa Iowa Amanda Bowen Kent Pope Signed (1) The employer does not elect the employers’ liability coverage. Andrew J Garner agarner6977@gmail.com Owner Williamsburg Iowa Iowa Amanda Bowen Kent Pope Signed
221 2020-08-03 12:03 Anonymous (not verified) 167.142.196.238 Israel Moreno Proprietorship Po Box 186 Williams, IA 50271 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-12 Israel Moreno mikjuniormoreno@hotmail.com Williams Hamilton Iowa Justin J Malloy Myndi Grimsley Signed (1) The employer does not elect the employers’ liability coverage. Israel Moreno mikjuniormoreno@hotmail.com owner Williams Hamilton Iowa Justin J Malloy Myndi Grimsley Signed
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
1175 2022-07-05 07:56 Anonymous (not verified) 64.251.168.116 Daniel Alan Valburg Proprietorship 27656 SD Hwy 44 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-05 Dan A Valburg agflyer620@gwtc.net White River Mellette SD George Ludvic Julie Ludvik Signed (1) The employer does not elect the employers’ liability coverage. Daniel Alan Valburg agflyer620@gwtc.net proprieter White River mellette SD George Ludvik Julie Ludvik Signed
1176 2022-07-05 08:08 Anonymous (not verified) 64.251.168.116 Lucky Dude Proprietorship 27656 SD Hwy 44 WHITE RIVER SD 57579 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-05 Lucky Dude agflyer620@gwtc.net White River Mellette SD George Ludvik Julie Ludvik Signed (1) The employer does not elect the employers’ liability coverage. Lucky Dude agflyer620@gwtc.net proprietor White River mellette SD George Ludvik Julie Ludvik Signed
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
928 2022-02-17 19:46 Anonymous (not verified) 208.83.187.211 Eric Marsh Trucking LLC Limited Liability Company 1029 Davis Ave Westbrook MN 56183 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-17 Eric Marsh emt78@yahoo.com Westbrook Cottonwood MN Dustin Krick Sam Hansen Signed (1) The employer does not elect the employers’ liability coverage. Eric Marsh emt78@yahoo.com Self Westbrook Cottonwood MN Dustin Krick Sam Hansen Signed
275 2020-10-08 11:56 Anonymous (not verified) 166.224.213.71 Michael corcoran Proprietorship 311 e elm st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-07 Michael corcoran mikecorcoran1990@gmail.com West Union Fayette IA Heather corcoran Chris Fels Signed (1) The employer does not elect the employers’ liability coverage. Michael corcoran mikecorcoran1990@gmail.com Self West Union Fayette IA Heather corcoran Chris fels Signed
68 2020-02-19 12:00 Anonymous (not verified) 198.14.241.59 SIERRA ROOFING LLC Limited Liability Company 909 N ELM ST WEST LIBERTY IA 52776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-19 ABRAHAM GRANJENO SIERRA89@GMAIL.COM WEST LIBERTY MUSCATINE IOWA JOSE SALGADO ALEJANDRIA FRAUSTO Signed (1) The employer does not elect the employers’ liability coverage. ABRAHAM GANJENO SIERRA89@GMAIL.COM OWNER WEST LIBERTY MUSCATINE IOWA JOSE SALGADO ALEJANDRIA FRAUSTO Signed
645 2021-09-18 09:47 Anonymous (not verified) 208.68.114.238 CHL Roofing & Siding Inc Proprietorship 509 1/2 E A St, West Liberty, IA 52776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-18 Fabian Galvan Rodriguez fgalvanglez14@gmail.com West Liberty Muscatine Iowa Karina A Beltran Nereida Velez Signed (1) The employer does not elect the employers’ liability coverage. Fabian Galvan Rodriguez fgalvanglez14@gmail.com Self West Liberty Muscatine Iowa Karina A Beltran Nereida Velez Signed
666 2021-10-07 08:12 Anonymous (not verified) 208.126.166.149 Toribio Construction LLC Limited Liability Company 107 W Maxson Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-07 Jose Toribio osorioabigail0224@gmail.com West Liberty Muscatine IA Anthony Johnson Abigail Osorio Signed (1) The employer does not elect the employers’ liability coverage. Jose Toribio osorioabigail0224@gmail.com Owner West Liberty Muscatine IA Anthony Johnson Abigail Osorio Signed
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
616 2021-08-23 13:14 Anonymous (not verified) 173.25.153.19 Levon Proprietorship 210 S 41st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-23 Levon shheba sheebalevon@gmail.com West des Moines IA 50265 Polk county IA Alina sheeba Delon sheeba Signed (1) The employer does not elect the employers’ liability coverage. Levon sheeba sheebalevon@gmail.com Myself West des Moines IA 50265 Polk county IA Alina sheeba Delon sheeba Signed
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
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
441 2021-03-18 16:20 Anonymous (not verified) 173.25.156.33 CYALCO AVIATION LLC Limited Liability Company 3710 W. MILWAUKEE ST, SPENCER, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-03-18 WILLIAM A. VAN LENT bvl@veridian.net WEST DES MOINES POLK IOWA ERIN MONFORT NELSON COLE M. VAN LENT Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. WILLIAM A. VAN LENT bvl@veridian.net SAME WEST DES MOINES POLK IOWA ERIN MONFORT NELSON COLE M. VAN LENT Signed
611 2021-08-19 15:23 Anonymous (not verified) 97.125.53.119 Rogelio Lopez Casillas Proprietorship 1175 Office Park Road Apt 109 WDM, Iowa 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-21 Rogelio Lopez Casillas deb@piciowa.com West Des Moines Polk Iowa Debra Stratton Kelly K Denger Signed (1) The employer does not elect the employers’ liability coverage. Rogelio Lopez Casillas deb@piciowa.com subcontractor West Des Moines Polk Iowa Debra Stratton Kelly K Denger Signed
640 2021-09-16 22:43 Anonymous (not verified) 97.125.255.204 Morgan Group LLC Limited Liability Company 1124 7th St. West Des Moines, Iowa 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-16 Mackinley Charles Morgan Morgangroupllc@gmail.com West Des Moines Polk Iowa Deborah Renee Morgan Mark Steven Morgan Signed (1) The employer does not elect the employers’ liability coverage. Mackinley Charles Morgan Morgangroupllc@gmail.com Owner of company West Des Moines Polk Iowa Deborah Renee Morgan Mark Steven Morgan Signed
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
754 2021-11-19 08:27 Anonymous (not verified) 65.144.174.26 miguel albino Proprietorship 8760 cody dr. unit 107 west des moines I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-19 miguel albino albino.miguel627@gmail.com west des moines united states iowa humbeto albino johnothan albino Signed (1) The employer does not elect the employers’ liability coverage. miguel albino albino.miguel627@gmail.com self west des moines united states iowa humberto albino johnothan Signed
820 2022-01-03 10:41 Anonymous (not verified) 174.195.193.112 Wolverine Construction LLC Limited Liability Company 467 s 84th street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-03 steffan sheehey steffanrobert@gmail.com West Des Moines Dallas IA Christopher Sheehey Taylor Lyman Signed (1) The employer does not elect the employers’ liability coverage. steffan sheehey steffanrobert@gmail.com Manager West Des Moines Dallas IA Christopher Sheehey Marcus Hatcher Signed
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
872 2022-01-30 18:54 Anonymous (not verified) 75.162.11.91 Iowa Carpentry Construction Limited Liability Company 3000 University Ave #18105 West Des Moines,IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-30 Carlos Velazquez jlctrimcarpenter@gmail.com Wes Des Moines Polk Iowa Carlos Velazquez Martha Marca Signed (1) The employer does not elect the employers’ liability coverage. Iowa Carpentry Construcion iowacarpentryconstruction@gmail.com Worker West Des Moines Polk Iowa Carlos Velazquez Martha Marca Signed
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
880 2022-02-01 14:05 Anonymous (not verified) 207.45.88.5 Known Labs LLC Limited Liability Partnership 8350 Ep True Pkwy, UNIT 1201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-01 Marcus Antonio Smith mark@knownlabs.net West Des Moines Dallas IA Dan Morgan III Amber Smith Signed (1) The employer does not elect the employers’ liability coverage. Marcus Antonio Smith mark@knownlabs.net Owner West Des Moines IA IA Daniel Morgan III Amber Smith Signed
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
921 2022-02-17 12:38 Anonymous (not verified) 173.22.55.191 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. (1) I am not electing the employers’ liability coverage. 2022-02-17 Victor Holzworth holzconstruction@gmail.com Waukee Dallas Iowa Brandon Pratt Mariah Burgett Signed (1) The employer does not elect the employers’ liability coverage. Victor Holzworth holzconstruction@gmail.com Owner West Des Moines Polk Iowa Brandon Pratt Mariah Burgett Signed
922 2022-02-17 12:44 Anonymous (not verified) 173.22.55.191 Red Rock Hunt Club 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. (1) I am not electing the employers’ liability coverage. 2022-02-17 Victor Holzworth holzconstruction@gmail.com Waukee Dallas Iowa Brandon Pratt Mariah Burgett Signed (1) The employer does not elect the employers’ liability coverage. Victor Holzworth holzconstruction@gmail.com Owner West Des Moines Polk Iowa Brandon Pratt Mariah Burgett Signed
923 2022-02-17 12:49 Anonymous (not verified) 173.22.55.191 Fat Bus 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. (1) I am not electing the employers’ liability coverage. 2022-02-17 Victor Holzworth holzconstruction@gmail.com Waukee Dallas Iowa Brandon Pratt Mariah Burgett Signed (1) The employer does not elect the employers’ liability coverage. Victor Holzworth holzconstruction@gmail.com Owner West Des Moines Polk Iowa Brandon Pratt Mariah Burgett Signed
987 2022-03-20 10:53 Anonymous (not verified) 75.162.173.186 John Greenman Painting Proprietorship 111 Village Drive West Des Moines Ia,50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-20 john greenman greenmanj55@gmail.com west des moines iowa iowa Angela Kay Olsem Peggy Ann Greenman Signed (1) The employer does not elect the employers’ liability coverage. John William Greenman greenmanj55@gmail.com owner west des moines iowa iowa Angela Kay Olsem Peggy Ann Greenman Signed
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
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
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
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
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
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
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
1504 2023-03-07 18:38 Anonymous (not verified) 94.188.207.227 Mathias Heating & Cooling Limited Liability Company 1449 19th Pl West Des Moines, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-07 Justin Mathias emathiasj@gmail.com West Des Moines Polk Iowa Jesse Parker Jeff Boucher Signed (1) The employer does not elect the employers’ liability coverage. Justin Mathias emathiasj@gmail.com Member West Des Moines Polk Iowa Jesse Parker Jeff Boucher Signed
1524 2023-03-20 09:00 Anonymous (not verified) 94.188.205.177 David Roman Proprietorship 8350 EP True Parkway, Apt 1101, West Des Moines, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-20 David Roman vida8147@gmail.com West Des Moines Dallas IA Dario Lucas Barrera Alfonso Montoya Signed (1) The employer does not elect the employers’ liability coverage. David Roman vida8147@gmail.com Self West Des Moines Dallas IA Dario Lucas Barrera Alfonso Montoya Signed
1557 2023-04-05 20:42 Anonymous (not verified) 94.188.207.228 Nava lawn care and junk hauling Limited Liability Company 220 2nd Street West Des Moines Iowa 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-05 Joan Nava Becerril jnb.2499@gmail.com West Des Moines IA United States Aylin Silva Garcia Arjan Silva Signed (1) The employer does not elect the employers’ liability coverage. Joan Nava Becerril info@navalawnandjunk.com OWNER West Des Moines IA United States Aylin Silva Garcia Arjan Silva Signed
1604 2023-04-26 09:03 Anonymous (not verified) 94.188.207.225 LeafHome Solutions LLC Limited Liability Company 3060 SE Grimes Boulevard Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Braedyn Baylor bbaylor66@gmail.com West des moines Polk Iowa Cassidy Tolle Jeffrey Baylor Signed (1) The employer does not elect the employers’ liability coverage. Braedyn Baylor bbaylor66@gmail.com Self West Des Moines Polk Iowa Julie Baylor Brianna Stephens Signed
1605 2023-04-26 09:48 Anonymous (not verified) 94.188.207.229 Double Barrell Construction Proprietorship 1237 S 52nd St, #804, West Des Moines, IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Braedyn Baylor bbaylor66@gmail.com West Des Moines Polk IA Peggy Toft Rick Thompson Signed (1) The employer does not elect the employers’ liability coverage. Braedyn Baylor bbaylor66@gmail.com Owner West Des Moines Polk IA Peggy Toft Rick Thompson Signed
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
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
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
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
2120 2024-03-27 15:31 Anonymous (not verified) 94.188.205.169 Dustin pleshe Proprietorship 6855 woodland ave unit 505 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-27 Dustin Pleshe dustinjpleshe@gmail.com WEST DES MOINES Iowa United States Kasey Cunningham Kathy Cunningham Signed (1) The employer does not elect the employers’ liability coverage. Dustin Pleshe dustinjpleshe@gmail.com He is me WEST DES MOINES Iowa United States Kasey cunningham Kathy cunningham Signed
2161 2024-04-18 15:40 Anonymous (not verified) 94.188.205.176 Thad A Holdefer Proprietorship 313 Ruthella Drive West Burlington, IA 52655 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Thad A. Holdefer thadholdefer@yahoo.com West Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Thad A Holdefer thadholdefer@yahoo.com owner West Burlington Des Moines Iowa Cheryl Ross Larry Rheinschmidt 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
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
1679 2023-06-06 08:27 Anonymous (not verified) 94.188.205.174 Remys Drywall LLC Proprietorship 42 Hoover Blvd West Branch, IA 52358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-06 Remigio M Juan remmateojuan1997@gmail.com West Branch Cedar IA Brad Bower Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Remigio M Juan remmateojuan1997@gmail.com Self West Branch Cedar IA Brad Bower Chris Hay Signed
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
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
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
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
629 2021-09-01 09:44 Anonymous (not verified) 204.155.61.217 Thrapp Electric Proprietorship 708 2nd Street Wellman, Iowa 52356 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-01 Jay Thrapp socketman5555@hotmail.com Wellman Washington Iowa Jeffrey Spenner Shawn Powell Signed (1) The employer does not elect the employers’ liability coverage. Jay Thrapp socketman5555@hotmail.com Owner Wellman Washington Iowa Jeffrey Spenner Shawn Powell Signed
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
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
270 2020-09-25 10:14 Anonymous (not verified) 174.243.97.206 J Watts Electric Limited Liability Company 615 E 2nd St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-25 Jason Watts jason.watts@jwattselectric.com Webster City Hamilton Iowa Eli Ochoa Cody Ewing Signed (1) The employer does not elect the employers’ liability coverage. Jason Watts jason.watts@jwattselectric.com Self Webster City Hamilton Iowa Eli Ochoa Cody Ewing Signed
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
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
415 2021-03-01 17:06 Anonymous (not verified) 208.126.61.78 Fryes Tree Service Proprietorship P.O. Box 244 Webster City, IA 50595 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-01 Don Johnson fts.don@gmail.com Webster City Hamilton IA Jenna Shaw Tim Turner Signed (1) The employer does not elect the employers’ liability coverage. Don Johnson fts.don@gmail.com Owner Webster City Hamilton IA Jenna shaw Tim Turner Signed
1561 2023-04-10 07:35 Anonymous (not verified) 94.188.207.227 All season gutter Limited Liability Company 1790 187th street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-10 Shane Harold schnittjer allseasongutter@outlook.com Webster city Hamilton Iowa Andrea Rae schnittjer Shane Ethan schnittjer Signed (1) The employer does not elect the employers’ liability coverage. Shane Harold schnittjer allseasongutter@outlook.com Self Webster City Hamilton Iowa Andrea Rae schnittjer Shane Ethan schnittjer Signed
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
1656 2023-05-22 11:48 Anonymous (not verified) 94.188.205.169 Cesar Arroyo Proprietorship 2207 Lisa Drive, Webster City IA 50595 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-18 Cesar Arroyo office.seamlesspros@icloud.com Webster City Hamilton Iowa Jessica Knutson Keith Clabaugh Signed (1) The employer does not elect the employers’ liability coverage. Cesar Arroyo office.seamlesspros@icloud.com Self Webster City Hamilton Iowa Jessica Knutson Keith Clabaugh Signed
1658 2023-05-23 09:56 Anonymous (not verified) 94.188.205.168 M&D Webster Construction Inc Proprietorship 1012 Creek Street Webster City IA 50595 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 David Gomez office.seamlesspros@icloud.com Webster City Hamilton Iowa Jessica Knutson Keith Clabaugh Signed (1) The employer does not elect the employers’ liability coverage. David Gomez office.seamlesspros@icloud.com Self Webster City Hamilton Iowa Jessica Knutson Keith Clabaugh Signed
788 2021-12-14 09:36 Anonymous (not verified) 162.250.36.34 Sylvester Enterprises, LLC Limited Liability Company 4800 Sylvester Rd. Webb, Ia. 51366 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-14 Tim Christian Sylvester isusly89@gmail.com Webb Clay Iowa Dennis Dwain Somers LInda Elayne Somers Signed (1) The employer does not elect the employers’ liability coverage. Tim Christian Sylvester slyenterprisesllc20@gmail.com Owner Webb Clay Iowa Dennis Dwain Somers Linda Elayne Somers Signed
789 2021-12-14 09:39 Anonymous (not verified) 162.250.36.34 Sylvester Enterprises, LLC Limited Liability Company 4800 Sylvester Rd. Webb, Iowa 51366 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-14 Christian Grant Sylvester slyfarms97@gmail.com Webb Clay iowa Dennis Dwain Somers LInda Elayne Somers Signed (1) The employer does not elect the employers’ liability coverage. Tim Christian Sylvester slyenterprisesllc20@gmail.com Owner Webb Clay Iowa Dennis Dwain Somers Linda Elayne Somers Signed
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
762 2021-11-22 09:23 Anonymous (not verified) 71.34.169.117 Oscar Lopez Proprietorship 1175 Office Park Road Apt 109 West Des Moines, Iowa 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-15 Oscar Lopez deb@piciowa.com WDM Polk ia Debra Stratton Kelly Denger Signed (1) The employer does not elect the employers’ liability coverage. Oscar Lopez deb@piciowa.com self WDM Polk IA Debra Stratton Kelly Denger Signed
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
124 2020-04-16 12:07 Anonymous (not verified) 96.3.180.122 Gold Rush, LLC Limited Liability Company 1395 130TH ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-16 Jay Christopher Morrow jcmorrow2@hotmail.com WAYLAND Henry IAUS chad mitchell Jonathan Mitchell Signed (1) The employer does not elect the employers’ liability coverage. Gold Rush, LLC jcmorrow2@gmail.com Self WAYLAND Henry IAUS chad mitchell Jonathan Mitchell Signed
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
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
127 2020-04-24 09:18 Anonymous (not verified) 63.152.82.5 TD Auto Services LLC Limited Liability Company 451 W Parker St Waterloo IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-27 Dakoda Sellers dakoda.d.sellers@gmail.com Waverly Bremer IA Jennie Roster Dustin Roster Signed (1) The employer does not elect the employers’ liability coverage. Dakoda D Sellers dakoda.d.sellers@gmail.com Owner Waverly Bremer IA Jennie Roster Dustin Roster Signed
700 2021-10-29 11:04 Anonymous (not verified) 174.198.66.50 T&C Lawn Care LLC Limited Liability Partnership 1827 Black Hawk St Waterloo IA 50702 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-29 Cody R Woodley cody.woodley50@gmail.com Cedar Falls Blackhawk Iowa Tara R Woodley Sara Woodley Signed (1) The employer does not elect the employers’ liability coverage. Kristi S. Demuth Agency, Inc. kdemuth@amfam.com Client Waverly Bremer Iowa Cody R Woodley Tyler M Croft Signed
991 2022-03-21 15:25 Anonymous (not verified) 64.191.6.226 Wheeler Painting Proprietorship 102 Maple Circle Waverly Iowa 50677 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-21 Jon Wheeler jon.wheeler67@gmail.com Waverly Bremer Iowa Jason Grant Richard Grant Signed (1) The employer does not elect the employers’ liability coverage. Jon Wheeler jon.wheeler67@gmail.com Owner Waverly Bremer Iowa Jason Grant Richard Grant Signed
1405 2023-01-04 11:56 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 Travis Duncan projects@duncanhs.com Waverly IA United States Alethea Duncan Kristine Fisher Signed (1) The employer does not elect the employers’ liability coverage. Travis Duncan projects@duncanhs.com self Waverly IA United States Alethea Duncan Kristine Fisher 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
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
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
952 2022-03-05 18:23 Anonymous (not verified) 108.59.100.21 Heaven Sent PC LLC Limited Liability Company 604 Allamakee St, Waukon,IA 52172 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-01 Justin Piggott heavensentpetcremation@gmail.com Waukon Allamakee Iowa Kaia Piggott Jane M Regan Signed (1) The employer does not elect the employers’ liability coverage. Justin Piggott heavensentpetcremation@gmail.com Member of LLC Waukon Allamakee Iowa Kaia Piggott Jane M Regan Signed
1201 2022-07-11 20:19 Anonymous (not verified) 108.59.100.21 Craig A Selberg dba Selberg Construction Proprietorship 853 North Fork Hollow Rd, Waukon IA 52172 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 Craig A Selberg selberg.construction65@gmail.com Waukon Allamakee Iowa Jane M Regan Nancy K Bechtel Signed (1) The employer does not elect the employers’ liability coverage. Craig A Selberg selberg.construction65@gmail.com Employer/Owner Waukon Allamakee Iowa Jane M Regan Nancy K Bechtel Signed
2144 2024-04-10 14:23 Anonymous (not verified) 94.188.205.176 Heaven Sent PC LLC Limited Liability Company 604 Allamakee St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-10 Justin PIggott heavensentpetcremation@gmail.com Waukon Allamakaee IA Jane M Regan Nancy Bechtel Signed (1) The employer does not elect the employers’ liability coverage. Justin Piggott heavensentpetcremation@gmail.com LLC Member Waukon Allamakee IA Jane M Regan Nancy Bechtel Signed
110 2020-04-06 14:13 Anonymous (not verified) 99.203.98.177 Stifel seasonal services Limited Liability Company 935 4th street waukee I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-06 Dalton Stifel daltonstifel@icloud.com waukee Dallas IA Bryant ternes Tammy stifel Signed (1) The employer does not elect the employers’ liability coverage. Dalton Stifel daltonstifel@icloud.com Owner waukee Dallas IA Bryant Ternes Tammy Stifel Signed
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
117 2020-04-11 09:08 Anonymous (not verified) 72.255.83.134 MIDWEST AG SOLUTIONS, LLC Limited Liability Company 4949 PLEASANT ST, STE 204, WEST DES MOINES, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-11 DALE A EASTMAN dale@emdsm.com Waukee Dallas IA Gary Marshall Brittain Bachus Signed (1) The employer does not elect the employers’ liability coverage. DALE A EASTMAN dale@emdsm.com same WAUKEE DALLAS IA GARY MARSHALL BRITTAIN BACHUS Signed
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
296 2020-10-29 09:39 Anonymous (not verified) 174.243.81.9 Alex Vanderbeek Proprietorship 85 NE Grace Wood Drive, Waukee, Iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-29 Alex Vanderbeek Vanderbeek17151@gmail.com Waukee Dallas Iowa Joe Simpson James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Alex Vanderbeek Vanderbeek17151@gmail.com self WAUKEE IA United States Joe Simpson James Nelson Signed
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
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
842 2022-01-17 16:29 Anonymous (not verified) 172.58.87.164 The Green Boys Limited Liability Company 55 Southeast Windfield Parkway I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-17 Emilio Belismelis emiliobelismelis87@gmail.com Waukee IA United States Lorena Belismelis Lorena Belismelis Signed (1) The employer does not elect the employers’ liability coverage. The Green Boys emiliobelismelis87@gmail.com Owner Waukee IA United States Emilo Belismelis Maria Belismelis Signed
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
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
1012 2022-03-28 14:42 Anonymous (not verified) 97.125.50.9 Charles Grimes Proprietorship 1041 NW Victoria Ln, Waukee, IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 Charles Grimes maurcedes98@gmail.com Waukee Dallas Iowa Dave Tomlin Lavon Grimes Signed (1) The employer does not elect the employers’ liability coverage. Charles Grimes maurcedes98@gmail.com self Waukee Dallas IA Dave Tomlin Lavon Grimes Signed
1255 2022-08-15 11:18 Anonymous (not verified) 173.215.77.92 Abby Snyder Design LLC Limited Liability Company 1540 SE Greenbriar Circle, Waukee, IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-15 Abby Mae Snyder abby.mae.snyder@gmail.com Waukee Dallas Iowa Jenni Wiig Katy Hildman Signed (1) The employer does not elect the employers’ liability coverage. Abby Mae Snyder abby.mae.snyder@gmail.com Self Waukee Dallas Iowa Jenni Wiig Katy Hildman Signed
1374 2022-11-17 14:33 Anonymous (not verified) 72.106.129.202 Cowman Consulting and Construction LLC Limited Liability Company 740 NE Horizon Dr, Waukee IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-17 Khalid Cowman khalidcowman1@gmail.com Waukee Dalls Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Khalid Cowman khalidcowman1@gmail.com Self/Owner Waukee Dallas Iowa Charlotte Rasmussen Austin Miller Signed
1451 2023-02-13 13:27 Anonymous (not verified) 94.188.205.168 Better Built Floors, LLC Limited Liability Company 950 Spruce street Waukee, IA, 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-13 Bodhi Cox betterbuiltfloors@gmail.com waukee dallas iowa Bodhi Cox Daniel Cox Signed (1) The employer does not elect the employers’ liability coverage. Bodhi Cox betterbuiltfloors@gmail.com i am thge owner/operator waukee dallas iowa Bodhi Cox Daniel Cox Signed
1474 2023-02-20 19:48 Anonymous (not verified) 94.188.207.230 Individual entity Proprietorship 801 CELTIC DR, Waukee IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Gerardo Castro jackiecastro18@gmail.com Waukee IA United States Jackelin Castro Esmeralda Castro Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Castro jackiecastro18@gmail.com self Waukee Dallas Iowa Jackelin Castro Esmeralda Castro Signed
1797 2023-08-14 09:37 Anonymous (not verified) 94.188.205.175 SCG Limited Liability Company 307 Bridge St. Redfield, IA 50233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-01 David Dwight Willis d.dubbaits@yahoo.com Redfield Dallas Iowa Lindsey Willis Sam Samuelson Signed (1) The employer does not elect the employers’ liability coverage. Ross Turner RTurner@holmesmurphy.com Agent Waukee Dallas Iowa Brain Paterson Brandon DeGroff Signed
1932 2023-12-01 20:02 Anonymous (not verified) 94.188.205.168 Wasabi Johnston LLC Limited Liability Company 2965 SE Timberline dr, Waukee, IA, 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-01 Enjin zheng jimmyzheng1573@gmail.com Waukee Dallas Iowa Jenna Yu Wen Zheng Signed (1) The employer does not elect the employers’ liability coverage. Enjin zheng jimmyzheng1573@gmail.com Owner Waukee Dallas Iowa Jenna Yu Wen Zheng Signed
1982 2024-01-11 12:29 Anonymous (not verified) 94.188.205.166 Grace Justine Proprietorship 405 Northview Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-11 Grace Justine Wandera / Independent Contractor justine.wandera@candeoiowa.org Waukee IA IA Grace Justine Wandera / Independent Contractor Grace Justine Wandera / Independent Contractor Signed (1) The employer does not elect the employers’ liability coverage. Grace Justine Wandera / Independent Contractor justine.wandera@candeoiowa.org own Waukee IA IA Grace Justine Wandera / Independent Contractor Grace Justine Wandera / Independent Contractor Signed
1986 2024-01-16 12:18 Anonymous (not verified) 94.188.207.229 Wasabi Urbandale LLC Limited Liability Company 2965 Se Timberline dr , Waukee , Iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-16 Enjinzheng jimmyzheng1573@gmail.com Waukee Dallas Iowa Jie Li Yingnazheng Signed (1) The employer does not elect the employers’ liability coverage. Enjin zheng jimmyzheng1573@gmail.com Owner Waukee Dallas Iowa Jie Li Yingna zheng Signed
2132 2024-04-03 19:49 Anonymous (not verified) 94.188.205.166 Soto Stone LLC Limited Liability Partnership 1071 mansfield Dr waukee iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-03 Yesser Lenin Juarez Soto sotostonellc95@gmail.com waukee Dallas Iowa Ashley Marie Francisco Vincent Alexander Flores Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Yesser Lenin Juarez Soto sotostonellc95@gmail.com self waukee Dallas Iowa Ashley Marie Francisco Vincent Alexander Flores Signed
2133 2024-04-03 19:58 Anonymous (not verified) 94.188.207.228 Soto Stone LLC Limited Liability Company 1071 mansfield Dr waukee iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-03 Yesser Lenin Juarez Soto sotostonellc95@gmail.com waukee Dallas Iowa Ashley Marie Francisco Vincent Alexander Flores Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Yesser Lenin Juarez Soto sotostonellc95@gmail.com self waukee Dallas Iowa Ashley Marie Francisco Vincent Alexander Flores Signed
2172 2024-04-22 14:09 Anonymous (not verified) 94.188.205.167 Melissa J Madison Proprietorship 326 NE Olivewood Waukee, IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-22 Melissa Janelle Madison melissamadison01@gmail.com Waukee DALLAS IOWA Haley Sears Scott Leinen Signed (1) The employer does not elect the employers’ liability coverage. Melissa Madison melissamadison01@gmail.com myself Waukee Dallas Iowa Haley Sears Scott Leinen Signed
158 2020-05-18 13:58 Anonymous (not verified) 108.59.100.21 LNM Truck & Trailer Repair LLC Limited Liability Company 902 Rossville Rd, Waukon, IA 52172 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-05-18 Matthew Hawkins lnmtruckandtrailerrepair@gmail.com Waterville Allamakee IA Jane M Regan Chelsea Whalen Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Matthew Hawkins lnmtruckandtrailerrepair@gmail.com Owner Waterville Allamakee IA Jane M Regan Chelsea Whalen Signed
735 2021-11-11 14:10 Anonymous (not verified) 72.13.16.172 T MILLER TRUCKING LLC Limited Liability Company 1682 MONROE DRIVE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 T MILLER TRUCKING LLC DAVE@ALLSEASONSTRUCKING.COM WATERVILLE ALLAMAKEE IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. T MILLER TRUCKING LLC dave@allseasonstrucking.com PRESIDENT WATERVILLE ALLAMAKEE IA Dave Neuwohner BEN MOYER Signed
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
153 2020-05-12 12:58 Anonymous (not verified) 172.58.86.150 Big Head Burger Limited Liability Company 706 Quincy st. Waterloo, Iowa 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-12 David Westley Bryant questions.bhb@gmail.com Waterloo Black Hawk Iowa Darlean Crawford Everlue Kincaid Signed (1) The employer does not elect the employers’ liability coverage. David Westley Bryant questions.bhb@gmail.com Owner Waterloo Black Hawk Iowa Darlean Crawford Everlue Kincaid Signed
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
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
503 2021-05-05 11:27 Anonymous (not verified) 50.82.130.211 Davonius Reed Limited Liability Company 1913 Upton Avenue, Waterloo IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-01 Davonius Reed cmins_re@mchsi.com Waterloo Black Hawk IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Davonius Reed cmins_re@mchsi.com Self Waterloo Black Hawk IA Chad Campbell Roxanne Kolder Signed
509 2021-05-10 15:25 Anonymous (not verified) 108.190.5.14 Shift Transport LLC Limited Liability Company 4215 Kris Line Drive Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-10 Damir Pajazetovic damirp2015@gmail.com Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed (1) The employer does not elect the employers’ liability coverage. Adnan Pajazetovic adoni.shift@gmail.com Owner Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed
510 2021-05-10 15:27 Anonymous (not verified) 108.190.5.14 Shift Transport LLC Limited Liability Company 4215 Kris Line Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-10 Adnan Pajazetovic Adoni.shift@gmail.com Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed (1) The employer does not elect the employers’ liability coverage. Adnan Pajazetovic adoni.shift@gmail.com Owner Waterloo Black Hawk Iowa Fata Pajazetovic Melda Pajazetovic Signed
606 2021-08-17 12:25 Anonymous (not verified) 69.57.199.231 Precision Painting Proprietorship 507 Broad St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-08-17 Daniel Paul Bowser danshonda12@gmail.com Reinbeck Grundy Iowa David Paul Bowser Mary Ellen Sue Bowser Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Sinnott Agency toms@sinnottagency.com Insurance provider Waterloo Blackhawk Iowa David Paul Bowser Mary Ellen Sue Bowser Signed
607 2021-08-17 12:31 Anonymous (not verified) 69.57.199.231 Precsion Painting Proprietorship 507 Broad St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-17 Daniel Paul Bowser danshonda12@gmail.com Reinbeck Grundy Iowa David Paul Bowser Mary Ellen Sue Bowser Signed (1) The employer does not elect the employers’ liability coverage. Sinnott Agency toms@sinnottagency.com Insurance provider Waterloo Blackhawk Iowa David Paul Bowser Mary Ellen Sue Bowser Signed
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
705 2021-11-02 11:41 Anonymous (not verified) 173.23.180.159 Simri Enterprise LLC Limited Liability Company 614 Ricker St Waterloo, IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-02 Noemi Del Carmen Trinidad simdelenterprisellc@gmail.com Waterloo Black Hawk Iowa Karla Axume Helmer Linares Signed (1) The employer does not elect the employers’ liability coverage. Simri Y Aldana simdelenterprisellc@gmail.com Owner Waterloo Black Hawk Iowa Karla Axume Helmer Linares Signed
707 2021-11-03 15:30 Anonymous (not verified) 173.23.180.159 Simdel Enterprise LLC Limited Liability Company 614 Ricker St Waterloo, IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-03 Noemi Del Carmen Trinidad simdelenterprisellc@gmail.com Waterloo Black Hawk Iowa Karla Axume Helmer Linares Axume Signed (1) The employer does not elect the employers’ liability coverage. Simri Y Aldana simdelenterprisellc@gmail.com Owner Waterloo Black Hawk Iowa Karla Axume Helmer Linares Axume Signed
708 2021-11-03 15:37 Anonymous (not verified) 173.23.180.159 Simdel Enterprise LLC Limited Liability Company 614 Ricker St. Waterloo, IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-03 Simri Yonelda Aldana Leiva simdelenterprisellc@gmail.com Waterloo Black Hawk Iowa Karla Axume Helmer Linares Axume Signed (1) The employer does not elect the employers’ liability coverage. Noemi Del Carmen Trinidad simdelenterprisellc@gmail.com Owner Waterloo Black Hawk Iowa Karla Axume Helmer Linares Axume Signed
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
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
909 2022-02-10 08:03 Anonymous (not verified) 166.181.83.242 Kim Hildebrand Proprietorship 130 Sabrina cir Waterloo, IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-07 Kimberly Kay Hildebrand kimregenold@yahoo.com Waterloo Blackhawk Iowa Darrin Hildebrand Stephanie Nerison Signed (1) The employer does not elect the employers’ liability coverage. Kimberly Kay Hildebrand kimregenold@yahoo.com Self Waterloo Blackhawk Iowa Darrin Hildebrand Stephanie Nerison Signed
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
982 2022-03-17 09:22 Anonymous (not verified) 65.132.173.234 DAVE GARDNER CONSTRUCTION Proprietorship 11936 KIMBALL AVE WATERLOO IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-17 DAVE GARDNER djg201312@gmail.com Waterloo Black Hawk Iowa Amy Picha Gary Rankin Signed (1) The employer does not elect the employers’ liability coverage. Dave Gardner djg201312@gmail.com self Waterloo Black Hawk IA Amy Picha Gary Rankin Signed
1132 2022-05-28 12:01 Anonymous (not verified) 166.181.81.175 Kamp Trucking LLC Limited Liability Company 3411 doris lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-28 Joseph Michael Kamp boss4z9@yahoo.com waterloo Iowa United States Glenn Harrison Bearbower April Ann Bearbower Signed (1) The employer does not elect the employers’ liability coverage. Joseph Michael Kamp boss4z9@yahoo.com same person. I am an owner operator waterloo Iowa United States Glenn Harrison Bearbower April Ann Bearbower Signed
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
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
1214 2022-07-20 09:51 Anonymous (not verified) 173.23.180.117 Eric Morse Proprietorship 1610 Hawthorne Ave, Waterloo, IA 50702 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-09 Eric Richard Morse ericmorse82@gmail.com Waterloo Black Hawk Iowa Christine Diane Willis (notary) Steve Sprague Signed (1) The employer does not elect the employers’ liability coverage. Eric Morse ericmorse82@gmail.com Self Waterloo Black Hawk Iowa Christine Diane Willis (notary) Steven Sprague Signed
1325 2022-10-02 20:07 Anonymous (not verified) 50.80.107.101 Hanson Custom Cleanup and Removal LLC Limited Liability Company 1221 Fleur Dr. Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-02 Jason Jacob Hanson jasonhanson1985@gmail.com Waterloo Blackhawk Iowa Cindy Shreve Jacob Ring Signed (1) The employer does not elect the employers’ liability coverage. Jason Hanson jasonhanson1985@gmail.com Self Waterloo Blackhawk Iowa Cindy Shreve Jacob Ring Signed
1334 2022-10-14 08:28 Anonymous (not verified) 67.212.98.135 Verbraken's New Look Painting & Decorating Proprietorship 147 Barryington Dr. Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-14 Donald Verbraken verbptg@aol.com Waterloo Black Hawk Iowa Cody Stoppel Rusty Donnelly Signed (1) The employer does not elect the employers’ liability coverage. Donald Verbraken verbptg@aol.com Owner Waterloo Black Hawk Iowa Cody Stoppel Rusty Donnelly Signed
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
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
1435 2023-01-31 14:33 Anonymous (not verified) 174.215.242.112 Premier builders Proprietorship 1821 East Ridgeway I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-31 Edward Koch etkdbq@aol.com Waterloo IA United States Glenda mclarty Coen Koch Signed (1) The employer does not elect the employers’ liability coverage. Edward Koch etkdbq@aol.com Owner Waterloo IA United States Glenda Mclarty Coen Koch Signed
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
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
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
1649 2023-05-16 11:37 Anonymous (not verified) 94.188.205.175 DEL-TA RESOURCE STAFFING, LLC Limited Liability Company 17735 pinyon lane, Dallas TX 75252 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-16 Solomon Solomon solomon@del-taresourcestaffing.com Dallas Dallas TX John Effang Eric Ijie Signed (1) The employer does not elect the employers’ liability coverage. Registered Agents Inc 315 E 5th St, STE 202 agent@washingtonregisteredagent.com Owner Waterloo Waterloo IA John Effang Eric Ijie Signed
1680 2023-06-06 12:08 Anonymous (not verified) 94.188.205.168 Sipac Drywall Proprietorship 1130 Columbia St, Waterloo, IA 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-06 Jennifer Sipac jenniferyoung164@gmail.com Waterloo Black Hawk Iowa Augie Ferguson Wendy Phillips Signed (1) The employer does not elect the employers’ liability coverage. Jennifer Sipac jenniferyoung164@gmail.com Owner Waterloo Black Hawk Iowa Augie Ferguson Wendy Phillips Signed
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
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
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
1955 2023-12-14 09:19 Anonymous (not verified) 94.188.207.229 Protouch snow&lawn llc Limited Liability Company 4015 sager ave waterloo I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-14 Eric brown brown39s@yhoo.com Waterloo United States Iowa Joe brown Emily brown Signed (1) The employer does not elect the employers’ liability coverage. Eric brown brown39s@yahoo.com Self Waterloo United States Iowa Emily brown Joe brown Signed
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
2009 2024-01-29 22:59 Anonymous (not verified) 94.188.207.226 Kimberly Ruby Reyes Victoriano Proprietorship 1910 Eric ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-29 Kimberly Ruby Reyes Victoriano InOnePieceDrywall@gmail.com Waterloo Black Hawk Iowa Juan Jose Victoriano Ramirez Denir Billy Flores Signed (1) The employer does not elect the employers’ liability coverage. Kimberly Ruby Reyes Victoriano InOnePieceDrywall@gmail.com Owner Waterloo Black Hawk Iowa Juan Jose Victoriano Ramirez Fredy Perez Perez Signed
2050 2024-02-16 09:45 Anonymous (not verified) 94.188.207.224 Mario Construction Limited Liability Company 1755 Huntington Rd Waterloo IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-16 Mario Lainez brocalainez73@gmail.com Waterloo Black Hawk Iowa Karolina Saenz Alejandra Maradiaga Signed (1) The employer does not elect the employers’ liability coverage. Mario Lainez brocalainez73@gmail.com Self Waterloo Black Hawk Iowa Karolina Saenz Alejandra Maradiaga Signed
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
2098 2024-03-15 18:38 Anonymous (not verified) 94.188.205.177 OMG Bros, LLC Limited Liability Partnership 404 Ivanhoe Rd, Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-03-15 Oscar Omar Gaytan og210666@gmail.com Waterloo Black Hawk Iowa Kaden Lyle Jake Usher Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Tristan Anthony Siebrands omgservices@omgbros.org Partner Waterloo Black Hawk Iowa Kaden Lyle Jake Usher Signed
2099 2024-03-15 18:50 Anonymous (not verified) 94.188.205.174 OMG Bros, LLC Limited Liability Partnership 404 Ivanhoe Rd, Waterloo, IA 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-03-15 Marco Antonio Gaytan marcogaytan77@gmail.com Waterloo Black Hawk Iowa Kaden Lyle Arayely Vazquez Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Tristan Anthony Siebrands omgservices@omgbros.org Partner Waterloo Black Hawk Iowa Kaden Lyle Arayely Vazquez Signed
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
2211 2024-05-08 12:39 Anonymous (not verified) 94.188.207.227 Barron Carpentry & Renovations LLC Limited Liability Company 1925 E 29th St. Des Moines, IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-07 Guillermo Barron barroncarpentry.renovations@gmail.com Des Moines POLK IOWA Abigail Hernandez Colima Diane Garcia Signed (1) The employer does not elect the employers’ liability coverage. Registered Agents INC. agent@iowaregisteredagent.com Registered agent Waterloo Black Hawk IOWA Abigail Hernandez Colima Diane Garcia 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
628 2021-09-01 09:39 Anonymous (not verified) 204.155.61.217 Utzinger Epoxy & Concrete, LLC Limited Liability Company 1595 Highway 1 Washington, Iowa 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. 2021-09-01 Troy Utzinger tbutzinger99@kctc.net Washington Washington Iowa Jeffrey Spenner Shawn Powell Signed (1) The employer does not elect the employers’ liability coverage. Troy Utzinger tbutzinger99@kctc.net owner Washington Washington Iowa Jeffrey Spenner Shawn Powell 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
545 2021-06-22 12:58 Anonymous (not verified) 97.88.95.170 Peter L. Viscusi Proprietorship 328 Jones Avenue, Warrensburg, MO 64093 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-22 Peter L. Viscusi pviscusi@charter.net Warrensburg Johnson Missouri Bradley S. McGuffey Randel C. Kyle Signed (1) The employer does not elect the employers’ liability coverage. Peter L. Viscusi pviscusi@charter.net Self Warrensburg Johnson Missouri Bradley S. McGuffey Randel C. Kyle Signed
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
2177 2024-04-24 13:50 Anonymous (not verified) 94.188.205.175 Epic Tile and Bathroom Remodeling Proprietorship 815 Isett Ave Wapello, IA 52653 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-24 Bruce Conrad Briggs epictileiowa@gmail.com Wapello Louisa Iowa Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Bruce Conrad Briggs epictileiowa@gmail.com owner Wapello Louisa Iowa Cheryl Ross Larry Rheinschmidt Signed
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
1588 2023-04-19 11:04 Anonymous (not verified) 94.188.205.174 Peters Tree Service Proprietorship 205 Melrose 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. 2023-04-19 Timothy F Peters tim_peters1@hotmail.com Wall Lake Sac Iowa Bruce Paysen Roberta Paysen Signed (1) The employer does not elect the employers’ liability coverage. Timothy F Peters tim_peters1@hotmail.com Self Wall Lake Sac Iowa Brace Paysen Roberta Paysen 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
680 2021-10-18 13:58 Anonymous (not verified) 166.181.86.88 Gerald Jerome Proprietorship 2668 Wapsi Ridge Dr. Walker, IA 52352 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-18 Gerald Jerome geraldjerome373@ymail.com Walker IA United States Benjamin J Barkalow James M. Barkalow Signed (1) The employer does not elect the employers’ liability coverage. Gerald Jerome geraldjerome373@ymail.com Self employed Walker Linn Iowa Benjamin J Barkalow James M Barkalow Signed
1930 2023-12-01 10:20 Anonymous (not verified) 94.188.207.227 TriCounty Enterprises/ DeNeve Construction Limited Liability Company 5527 Crane Lane NE Cedar Rapids,IA 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-01 Rick Delayne Primmer rdprimmerroofing@gmail.com Walker Linn Iowa Jerry Wiltsey Robert Null Signed (1) The employer does not elect the employers’ liability coverage. Rick Delayne Primmer rdprimmerroofing@gmail.com Worker Walker Iowa Iowa Jerry Wiltsey Robert Null Signed
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
72 2020-02-21 09:43 Anonymous (not verified) 98.18.174.183 Forrest E. Whitford DVM LLC Limited Liability Company P.O. Box 120 - 507 Washington Street, Volga, IA 52077 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-21 Forrest E. Whitford, DVM LLC gfw54@hotmail.com Volga, IA Clayton Iowa Glenna Whitford Pam Vaske Signed (1) The employer does not elect the employers’ liability coverage. Forrest E. Whitford, DVM LLC gfw54@hotmail.com self Volga Clayton Iowa Glenna Whitford Pam Vaske Signed
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
1673 2023-06-02 09:30 Anonymous (not verified) 94.188.207.228 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Alyce Lynch kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1674 2023-06-02 09:34 Anonymous (not verified) 94.188.207.229 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Kyle Lynch kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1675 2023-06-02 09:37 Anonymous (not verified) 94.188.207.228 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Kevin Kacena kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owner - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1676 2023-06-02 09:41 Anonymous (not verified) 94.188.207.229 Kacena Family Tree Farm Inc Partnership 2510 55th St., Vinton, IA 52349 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-01 Debra Kacena kacenafarms.alyce@gmail.com Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed (1) The employer does not elect the employers’ liability coverage. Alyce Lynch ashlyn@3riversins.net 25% Owners - President Vinton Benton Iowa Ashlyn J. Christianson Angie McFarland Signed
1882 2023-10-27 10:40 Anonymous (not verified) 94.188.205.166 Ron's SIding and Construction Proprietorship 6097 26th Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2025-02-02 Ron Heggebo heggebojessica@yahoo.com Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed (1) The employer does not elect the employers’ liability coverage. Ronnie Heggebo heggebojessica@yahoo.com self Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed
1883 2023-10-27 10:49 Anonymous (not verified) 94.188.207.228 Ron's SIding and Construction Proprietorship 6097 26th Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-27 Ron Heggebo heggebojessica@yahoo.com Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed (1) The employer does not elect the employers’ liability coverage. Ron Heggebo heggebojessica@yahoo.com Self Vinton Benton IA Jessica Heggebo Jessica Heggebo Signed
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
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
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
1192 2022-07-07 21:15 Anonymous (not verified) 174.242.226.74 Quelland Flooring Limited Liability Company P.O. Box 5, Van Meter, IA, 50261 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Jared Tyler Quelland Jquelland@gmail.com Van Meter IA United States Denise Walters Madison Miller Signed (1) The employer does not elect the employers’ liability coverage. Jared Tyler Quelland Jquelland@gmail.com Self Van Meter IA United States Denise Walters Madison Mileer Signed
1417 2023-01-11 08:55 Anonymous (not verified) 174.235.209.245 Standard Insulation Company, LLC Limited Liability Company 1066 Prairieview Ave., Van Meter, IA 50261 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-11 Mitchell Simonson standard.insulation@outlook.com Van Meter Madison IA Jeremy Smith Sue Sherman Signed (1) The employer does not elect the employers’ liability coverage. Mitchell Simonson standard.insulation@outlook.com Owner Van Meter Madison IA Jeremy Smith Sue Sherman Signed
2015 2024-02-01 08:26 Anonymous (not verified) 94.188.207.223 Salazar Builders inc Proprietorship 29175 365th st van meter ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-01 José Luis ángeles Salazar salazarbuilders15@gmail.com Van meter ia Dallas Iowa Adam Paul Boge Lance Owen Webster Signed (1) The employer does not elect the employers’ liability coverage. Jose Luis angeles Salazar salazarbuilders15@gmail.com Sub contractor Van meter Dallas Iowa Adam Paul Boge Lance Owen Webster Signed
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
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
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
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
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
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
302 2020-10-31 13:04 Anonymous (not verified) 173.17.230.149 Absolute Construction Partnership 3720 Patricia Drive, Urbandale, Iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-31 Joe Simpson jrsimpson27@gmail.com Urbandale Polk Iowa Alex Vanderbeek James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Joe Simpson jrsimpson27@gmail.com self Urbandale Polk Iowa Alex Vanderbeek James Nelson Signed
662 2021-10-01 16:05 Anonymous (not verified) 174.242.224.18 Troy bryan Limited Liability Company 2800 68th st urbandale Iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-01 Troy bryan tbryan0015@gmail.com Urbandale Polk Iowa Brenna painter Marc bryan Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Troy bryan tbryan0015@gmail.com Owner Urbandale Polk Iowa Brenna painter Marc bryan Signed
692 2021-10-26 14:58 Anonymous (not verified) 65.144.174.26 Jake Kenney Proprietorship 3201 Hillsdale Dr. , Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-26 Jacob Daniel Kenney Jakedkenney@hotmail.com Urbandale Polk Iowa Abbey Kenney Jory Ringler Signed (1) The employer does not elect the employers’ liability coverage. Jacob Daniel Kenney jakedkenney@hotmail.com Owner Urbandale polk ia abbey kenney jory ringler Signed
1000 2022-03-23 10:24 Anonymous (not verified) 75.162.12.87 Eric Louvan Proprietorship 2840 104th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-23 Eric Louvan elouvan@phillipssstafford.com Ankeny Polk Iowa Brandon Johnson Ann Louvan Signed (1) The employer does not elect the employers’ liability coverage. Brad Phillips bphillips@phillipsstafford.com Employee Urbandale Polk IA Eric Louvan Luke Vanroekel Signed
1061 2022-04-19 19:30 Anonymous (not verified) 172.58.83.52 Rodolfo Perez Proprietorship 3420 E 12th St Des Moines Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-19 Rodolfo Perez Elgordo0738@gmail.com Des Moines Polk Iowa Henry santos Larry ramos Signed (1) The employer does not elect the employers’ liability coverage. Justin Lantz Info@lantzelite.com Self employed no workers Urbandale Polk Iowa Henry santos Larry ramos Signed
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
1195 2022-07-08 13:24 Anonymous (not verified) 174.198.67.66 Chapas Construction Limited Liability Company 6424 Roseland Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-08 Polibio Raul Chapa Farez chapasconstructionllc@gmail.com Urbandale IA IA Brenda Rivas Charlie Chapa Signed (1) The employer does not elect the employers’ liability coverage. Polibio Raul Chapa chapasconstructionllc@gmail.com President Urbandale IA IA Brenda Rivas Charlie Chapa Signed
1248 2022-08-09 11:29 Anonymous (not verified) 166.181.82.131 Kelly Kellogg Proprietorship 1305 N 1st st apt 16 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-09 Kelly Kkell0223@gmail.com Indianola Warren Iowa Kelly Kellogg Amy Kellogg Signed (1) The employer does not elect the employers’ liability coverage. Royal flooring workorders@shoproyalflooring.com Employee Urbandale Polk Iowa Amy Kelly Signed
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
1293 2022-09-03 08:03 Anonymous (not verified) 50.82.244.98 MTZ Drywall Proprietorship 1101 Eighth St, West Des Moines, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-02 Richar Martinez menace_42@icloud.com West Des Moines United States Iowa Alejandro Gonzalez Emilio Martinez Signed (1) The employer does not elect the employers’ liability coverage. Jerry Jenkins jjenkins@farmersagent.com N/A Urbandale United States Iowa Alejandro Gonzalez Emilio Martinez Signed
1384 2022-12-08 13:11 Anonymous (not verified) 172.58.81.43 Sehic G&S, LLC. Limited Liability Company 4201 62nd st apt 4 Urbandale Ia 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-09 Bajro sehic kalesija20@gmail.com Urbandale Polk Iowa N/A N/A Signed (1) The employer does not elect the employers’ liability coverage. Bajro sehic kalesija20@gmail.com Owner Urbandale Polk Iowa N/A N/A Signed
1395 2022-12-15 08:02 Anonymous (not verified) 172.58.84.122 Sehic G&S, LCC Limited Liability Company 4201 62nd st Urbandale iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-15 Bajro sehic kalesija20@gmail.com Urbandale Polk Iowa Bajro Bajro Signed (1) The employer does not elect the employers’ liability coverage. Bajro sehic kalesija20@gmail.com Owner Urbandale Dallas Iowa Bajro Bajro Signed
1459 2023-02-16 09:07 Anonymous (not verified) 94.188.205.166 Lakerats Limited Liability Company 112 W Court Winterset IA 50273 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-05 Kyra Moore kyra@novushomemortgage.com Urbandale Polk Iowa Jessica Anderson Easton Anderson Signed (1) The employer does not elect the employers’ liability coverage. Kyra Moore kyra@novushomemortgage.com Owner Urbandale Polk Iowa Jessica Anderson Easton Anderson Signed
1461 2023-02-17 07:48 Anonymous (not verified) 94.188.205.168 Great Blinds LLC Limited Liability Company 5174 Parkridge Ave Pleasant Hill, IA 50327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 Andrew Mohrfeld mohrfeldandy@yahoo.com Pleasant Hill Polk IA Andrew Mohrfeld Martin Mohrfeld Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. John Lovell Jon@jlovellco.com None Urbandale Polk IA Andrew Mohrfeld Martin Mohrfeld Signed
1514 2023-03-13 10:04 Anonymous (not verified) 94.188.205.166 MMK Electric Limited Liability Partnership 4515 84th St 84th Street Urbandale, Iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-13 Travis Miller mmk.iowa@gmail.com Urbandale Polk Iowa Elijah Kain Marshall McKay Signed (1) The employer does not elect the employers’ liability coverage. Travis Miller mmk.iowa@gmail.com Owner Urbandale Polk Iowa Elijah Kain Marshall McKay Signed
1520 2023-03-16 14:24 Anonymous (not verified) 94.188.205.167 MMK Electric Partnership 4515 84th Street Urbandale, Iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-16 Marshall Logan McKay mmk.iowa@gmail.com Des Moines Polk Iowa Travis Miller Elijah Kain Signed (1) The employer does not elect the employers’ liability coverage. Travis Miller mmk.iowa@gmail.com Owner Urbandale Polk Iowa Elijah Kain Travis Miller Signed
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
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
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
1796 2023-08-13 13:35 Anonymous (not verified) 94.188.205.176 Mirsad Mulic Limited Liability Company 7094 Hickory Ln I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-13 Mirsad Mulic finecarpentry30@icloud.com Urbandale Polk IA Peter Griffin Andy Dufre Signed (1) The employer does not elect the employers’ liability coverage. Fine Carpentry finecarpentry30@icloud.com Partner Urbandale Polk IA Griffin Peterson Andy Dufre Signed
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
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
1933 2023-12-01 20:29 Anonymous (not verified) 94.188.207.228 Wasabi Johnston 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. 2023-12-01 Yean Ching Sue soamie@hotmail.com Urbandale Dallas Iowa Enjin Zheng Wen Zheng Signed (1) The employer does not elect the employers’ liability coverage. Yean Ching Sue soamie@hotmail.com Owner Urbandale Dallas Iowa Enjin Zheng Wen Zheng 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
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
1985 2024-01-16 11:51 Anonymous (not verified) 94.188.205.167 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. 2024-01-16 Yean Ching Sue soamie@hotmail.com Urbandale Dallas Iowa Enjin Zheng Wen Zheng Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Yean Ching Sue soamie@hotmail.com Owner Urbandale Dallas Iowa Enjin Zheng Wen Zheng Signed
1987 2024-01-16 12:35 Anonymous (not verified) 94.188.207.229 Wasabi urbandale LLc Limited Liability Company 12509 Townsend Ava, 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. 2024-01-16 Wen Zheng jenna18841002@hotmail.com Urbandale Dallas Iowa Jie Li Yingna Zheng Signed (1) The employer does not elect the employers’ liability coverage. Wen Zheng jenna18841002@hotmail.com Owner Urbandale Dallas Iowas Jie Li Yingna zheng 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
2008 2024-01-29 14:45 Anonymous (not verified) 94.188.207.230 DB2P Limited Liability Company 5904 Ashworth Road I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-29 Arjun Dahal allcoolliquors@gmail.com West Des Moines Dallas Iowa Jayson Jones Nikki Wilks Signed (1) The employer does not elect the employers’ liability coverage. Jayson Jones jayson@jonesinsured.com Insurance Agent Urbandale Dallas Iowa Jayson Jones Nikki Wilks Signed
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
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
2215 2024-05-08 22:07 Anonymous (not verified) 94.188.207.223 Self Employed-Ryan Thornton Proprietorship 8403 Horton Ave Urbandale IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-08 Ryan M Thornton rt6366155@gmail.com Urbandale Polk Iowa April Oxendale Bruce Thornton Signed (1) The employer does not elect the employers’ liability coverage. Ryan Thornton rt6366155@gmail.com Self Urbandale Polk Iowa April Oxendale Bruce Thornton Signed
704 2021-11-01 18:43 Anonymous (not verified) 157.52.56.205 Martin Clip & Trim LLC Limited Liability Company 204 Oak Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-30 Armin Harold Martin arminbonnie@aol.com Urbana Benton Iowa Melissa Linn Stieferman Bronna Mae Gubbels Signed (1) The employer does not elect the employers’ liability coverage. Armin Harold Martin arminbonnie@aol.com self Urbana Benton Iowa Melissa Linn Stieferman Bronna Mae Gubbels Signed
1362 2022-11-08 08:36 Anonymous (not verified) 157.52.56.205 Martin Clip & Trim LLC Proprietorship Box 383 Urbana Iowa 52345 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-08 Armin Martin arminbonnie@aol.com Urbana Benton Iowa Melissa Stieferman Christin Martin Signed (1) The employer does not elect the employers’ liability coverage. Armin Martin arminbonnie@aol.com Self Urbana Benton Iowa Melissa Stieferman Christin Martin Signed
1511 2023-03-09 15:52 Anonymous (not verified) 94.188.205.177 CG Welding Limited Liability Company 5400 147th I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-09 Christopher A Lendt weldingiowa@gmail.com Urandale Dallas IA Chris Lendt Chris Lendt Signed (1) The employer does not elect the employers’ liability coverage. Christopher A Lendt weldingiowa@gmail.com Owner Urandale Dallas IA Christopher Lendt Christopher Lendt Signed
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
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
845 2022-01-20 09:06 Anonymous (not verified) 208.126.69.10 KenX Pest Control Limited Liability Company 350 2nd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-20 Ken YARRINGTON kenxpestcontrol@hotmail.com Truro IA IA James Gage Kent Smith Signed (1) The employer does not elect the employers’ liability coverage. Kenneth Charles Yarrington kenxpestcontrol@hotmal.com Myself Truro IA IA James Gage Kent Smith Signed
1467 2023-02-17 16:14 Anonymous (not verified) 94.188.205.169 H & C Construction Limited Liability Company 708 Vine Street Lucas IA 50151 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 Colton Charles Clarke ccclarke95@gmail.com Truro IA United States Hailey Sullivan Shelby Comer Signed (1) The employer does not elect the employers’ liability coverage. H & C Construction ccclarke95@gmail.com Manager Truro IA United States Hailey Sullivan Shelby Comer Signed
1508 2023-03-09 10:34 Anonymous (not verified) 94.188.205.176 H & C Construction Limited Liability Company 708 Vine Street Lucas IA 50151 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-09 Colton Charles Clarke ccclarke95@gmail.com Truro IA United States Hailey A Sullivan Shelby Comer Signed (1) The employer does not elect the employers’ liability coverage. Colton Charles Clarke ccclarke95@gmail.com Manager Truro IA United States Hailey A Sullivan Shelby Comer Signed
454 2021-03-26 09:46 Anonymous (not verified) 50.82.130.211 Jason Thoren Proprietorship 104 1st Street NW, Tripoli, IA 50676 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-04 Jason Thoren cmins_re@mchsi.com Tripoli Bremer Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Jason Thoren cmins_re@mchsi.com Self Tripoli Bremer Iowa Chad Campbell Roxanne Kolder Signed
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
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
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
377 2021-01-26 13:31 Anonymous (not verified) 184.63.6.1 Matt Reynolds Proprietorship 684 Cedar Valley Rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-26 Matt Reynolds matt.reynolds0891@gmail.com Tipton Cedar Iowa Anna Miller Steve Miller Signed (1) The employer does not elect the employers’ liability coverage. Matthew Reynolds matt.reynolds0891@gmail.com Proprietorship Tipton Cedar Iowa Anna Miller Steve Miller Signed
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
913 2022-02-14 18:50 Anonymous (not verified) 72.25.23.147 Teimer Trucking Limited Liability Company 3277 102nd St. Durant, IA 52747 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-14 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Cedar Iowa Barry Boll Jennifer Treimer Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Owner Tipton Cedar Iowa Barry Boll Jennifer Treimer Signed
1484 2023-02-25 16:42 Anonymous (not verified) 94.188.205.177 Carpenter wood shed/ rays longging Limited Liability Company 1631 230th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-27 Raymond Carpenter corinnafrymoyer@gmail.com tipton Cedar Iowa corinna frymoyer Levi carpenter Signed (1) The employer does not elect the employers’ liability coverage. Raymond Carpenter corinnafrymoyer@gmail.com Self Tipton Cedar Iowa Corinna frymoyer Levi carpenter Signed
1803 2023-08-15 19:03 Anonymous (not verified) 94.188.207.224 Teimer Trucking LLC Limited Liability Company 3277 102nd St. Durant, IA 52747-9524 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-15 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Iowa United States Spencer Lea Parsons Sydney Rae Lane Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Self Tipton Iowa United States Spencer Lea Parsons Sydney Rae Lane Signed
1808 2023-08-17 17:17 Anonymous (not verified) 94.188.205.168 Treimer Trucking LLC Limited Liability Company 3277 102nd St. Durant, IA 52747-9524 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-17 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Iowa United States Sydney Rae Lane Spencer Lea Parsons Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Self Tipton Iowa United States Syndey Rae Lane Spencer Lea Parsons Signed
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
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
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
949 2022-03-04 16:09 Anonymous (not verified) 173.20.147.171 Duwa Waterproofing LLC Limited Liability Company 729 Deer view Ave, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-04 Stacy Duwa duwawaterproofing@gmail.com Tiffin Johnson Iowa Lauren Obermann Don Vittetoe Signed (1) The employer does not elect the employers’ liability coverage. Stacy Duwa duwawaterproofing@gmail.com owner Tiffin Johnson Iowa Lauren Obermann Don Vittetoe Signed
954 2022-03-08 11:07 Anonymous (not verified) 174.192.138.191 Duwa Waterproofing Limited Liability Company 729 Deer View Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-08 Stacy Duwa duwawaterproofing@gmail.com Tiffin Johnson Iowa Chad Cooper Curtis Sexton Signed (1) The employer does not elect the employers’ liability coverage. Stacy Duwa duwawaterproofing@gmail.com President Tiffin Johnson Iowa Chad Cooper Curtis Sexton Signed
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
1316 2022-09-21 14:49 Anonymous (not verified) 184.81.198.17 Ellen Faye Stevenson Proprietorship 201 Stephans st. Tiffin, Iowa 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-21 Ellen Faye Stevenson nelle@southslope.net Tiffin Johnson Iowa Catherine Louise Nelson Joseph Roger Titone Signed (1) The employer does not elect the employers’ liability coverage. Ellen Faye Stevenson nelle@southslope.net myself Tiffin Johnson Iowa Catherine Louise Nelson Joseph Roger Titone Signed
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
1951 2023-12-12 13:10 Anonymous (not verified) 94.188.207.230 Patrick McGuinnis Limited Liability Company 5697 Squire Circle, Thomson, IL 61285 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-09 Patrick A McGinnis McGinnistrucking2023@yahoo.com Thomson Carroll IL Ashleigh McGuinnis Kimberly Williams Signed (1) The employer does not elect the employers’ liability coverage. Parick A McGunnis mcginnistrucking2023@yahoo.com Self Thomson Carroll IL Ashleigh McGinnis Kimberly Williams Signed
712 2021-11-05 10:38 Anonymous (not verified) 64.5.73.247 Glenn Langel Proprietorship 20581 300th St, Templeton, IA 51463 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-29 Glenn Langel gklangel@netins.net Templeton Carroll Iowa Jonathan Heydon Mitchell Langel Signed (1) The employer does not elect the employers’ liability coverage. Glenn Langel gklangel@netins.net Owner Templeton Carroll Iowa Jonathan Heydon Mitchell Langel Signed
713 2021-11-05 10:41 Anonymous (not verified) 64.5.73.247 Mitchell Langel Proprietorship 20581 300th St, Templeton IA 51463 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-29 Mitchell Langel gklangel@netins.net Templeton Carroll Iowa Jonathan Heydon Lacey Marsh Signed (1) The employer does not elect the employers’ liability coverage. Mitchell Langel gklangel@netins.net Owner Templeton Carroll Iowa Jonathan Heydon Lacey Marsh Signed
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
469 2021-04-12 16:49 Anonymous (not verified) 65.103.82.36 Stice Construction Proprietorship 13723 140th st W I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-07-22 Alex Stice Astice17@hotmail.com Taylor Ridge Rock Island IL Ashley Stice JIm Stice Signed (1) The employer does not elect the employers’ liability coverage. Alex Stice astice17@hotmail.com self taylor ridge rock island il Ashley stice Jim Stice Signed
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
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
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
1537 2023-03-27 13:21 Anonymous (not verified) 94.188.207.228 miller hybrids Limited Liability Company 1213 Larch Ave, Kalona, IA 52247 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Jeremy Wakerhauser jwakerhauser@gmail.com Sun Prairie WI United States Jeremy Wakerhauser Jeremy Wakerhauser Signed (1) The employer does not elect the employers’ liability coverage. Jeremy Wakerhauser jwakerhauser@gmail.com sole proprieter Sun Prairie WI United States Jeremy Wakerhauser Jeremy Wakerhauser Signed
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
1689 2023-06-13 19:55 Anonymous (not verified) 94.188.207.227 Gerardo Reyes-Lopez Limited Liability Company 908 West 1st Street, Waterloo, IA ,50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-13 Gerardo Reyes-lopez greyeslopez9@gmail.com Waterloo Black Hawk Iowa Guillermina Lopez Bernardo Reyes Signed (1) The employer does not elect the employers’ liability coverage. Denise Seitsinger denise@harmsinsuranceagency.com Insurance Agent Sumner Bremer Iowa Gerardo Reyes Bernardo Reyes Signed
1690 2023-06-13 20:01 Anonymous (not verified) 94.188.207.227 Gerardo Reyes-Lopez Limited Liability Company 908 West 1st Street, Waterloo, Iowa, 50701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-13 Gerardo Reyes-lopez bernardo@reyesconstruct.com Waterloo IA United States Guillermina Lopez Bernardo Reyes Signed (1) The employer does not elect the employers’ liability coverage. Denise Seitsinger denise@harmsinsuranceagency.com Insurance Agent Sumner Bremer Iowa Gerardo Reyes Bernardo Reyes Signed
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
2048 2024-02-16 07:42 Anonymous (not verified) 94.188.207.224 Alexandra Machedon LLC Proprietorship 319 N Western Street Stuart, IA 50250 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-16 Alexandra Machedon ali@alimachedon.com Stuart USA Iowa Jessica Cash Vicki Collins Signed (1) The employer does not elect the employers’ liability coverage. Alexandra Machedon ali@alimachedon.com Self Stuart US IA Jessi Cash Vicki Collins Signed
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
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
1044 2022-04-13 09:11 Anonymous (not verified) 166.181.81.114 Paul Wall Assemblies LLC Limited Liability Company 38165 Belgian rd. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-04-13 Paul Carnicle paulcarnicle@yahoo.com Strawberry Point Iowa United States Alexander Gabriel Guthrie Sebastin Thompsin Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Paul Carnicle paulcarnicle@yahoo.com Partner Strawberry Point Iowa United States Alexander Gabriel Guthrie Sebastin Thompson Signed
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
265 2020-09-21 14:41 Anonymous (not verified) 74.84.65.174 Nagol Enterprises Limited Liability Company 16124 PLEASANT VALLEY DR I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-21 Logan Victor Ante antelogan@gmail.com Story CIty Story iowa Brian Wade Warren Tyler Christian Thompson Signed (1) The employer does not elect the employers’ liability coverage. Logan Victor Ante antelogan@gmail.com Same Story CIty IA IA Brian Wade Warren Tyler Christian Thompson Signed
787 2021-12-13 16:15 Anonymous (not verified) 64.5.77.84 Heartland Counseling Services Limited Liability Company 813 Flindt Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-05 Kathleen Ruscitto info@heartlandcounselingia.com STORM LAKE Iowa United States David Kirk Michael Robertson Signed (1) The employer does not elect the employers’ liability coverage. Kathleen Ruscitto info@heartlandcounselingia.com Self/Owner STORM LAKE Iowa United States David Kirk Michael Robertson Signed
2042 2024-02-12 13:07 Anonymous (not verified) 94.188.205.175 Evelyn R Ventura Terrazas Proprietorship 524 Terrence I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-12 Evelyn R Ventura Terrazas evelynterrazas@gmail.com Storm Lake Buena vista IA Juan García Oropeza Karen Rodríguez Pantoja Signed (1) The employer does not elect the employers’ liability coverage. Evelyn R Ventura Terrazas evelynterrazas@gmail.com Proprietorship Storm Lake Buena vista IA Juan Garcia Oropeza Karen Rodríguez Pantoja Signed
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
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
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
1452 2023-02-13 16:49 Anonymous (not verified) 94.188.207.228 The Wine Shop, LLC Limited Liability Company 305 Main St, Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-02-13 Dana Swasand danaswasand@rocketmail.com Steamboat Rock Hardin Co. Iowa Jay Schares Nicole Erickson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Dana Swasand danaswasand@rocketmail.com Owner/Member Steamboat Rock Hardin Co. Iowa Jay Schares Nicole Erickson Signed
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
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
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
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
1761 2023-07-26 08:40 Anonymous (not verified) 94.188.207.224 Gerk Trucking Proprietorship 401 W college, Stacyville, IA 50476 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-26 Charles W. Gerk cwgerk@gmail.com Stacyville Mitchell iowa Jeannie Lemke Robin Tabbert Signed (1) The employer does not elect the employers’ liability coverage. Charles W. Gerk cwgerk@gmail.com Same Stacyville Mitchell Iowa Jeannie Lemke Robin Tabbert Signed
291 2020-10-25 11:06 Anonymous (not verified) 208.126.69.94 self-employed Proprietorship PO Box 15, 430 E. Iowa St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-25 Steven Fisher fishersjk@gmail.com St. Mary's Iowa United States Jodi Fisher Jenna Fisher Signed (1) The employer does not elect the employers’ liability coverage. Steven Fisher fishersjk@gmail.com same person St. Mary's Iowa United States Jodi Fisher Jenna Fisher Signed
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
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
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
2016 2024-02-01 09:20 Anonymous (not verified) 94.188.207.225 Imperium Outdoor Solutions Proprietorship 114 W Clanton St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-01 Austin Beener abeener033@gmail.com St Charles IA United States Austin Beener Austin Beener Signed (1) The employer does not elect the employers’ liability coverage. Austin Beener abeener033@gmail.com Operator St Charles IA United States Austin Beener Austin Beener Signed
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
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
745 2021-11-11 15:24 Anonymous (not verified) 72.13.16.172 SCHLECHT TRUCKING LLC Limited Liability Company 107 SOUTH 1ST STREET I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 SCHLECHT TRUCKING LLC dave@allseasonstrucking.com SPRINGBROOK JACKSON IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. SCHLECHT TRUCKING LLC dave@allseasonstrucking.com PRESIDENT SPRINGBROOK JACKSON IA Dave Neuwohner BEN MOYER Signed
736 2021-11-11 14:26 Anonymous (not verified) 72.13.16.172 All Seasons Trucking Inc Proprietorship S11689 CTY RD G I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 FARGEN TRUCKING dave@allseasonstrucking.com SPRING GREEN SAUK WI DAVE NEUWOHNER BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. FARGEN TRUCKING DAVE@ALLSEASONSTRUCKING.COM PRESIDENT SPRING GREEN SAUK WI Dave Neuwohner BEN MOYER Signed
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
357 2021-01-12 09:56 Anonymous (not verified) 173.31.147.225 SKYLAR INGRAHAM Proprietorship 903 9TH ST SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-12 SKYLAR INGRAHAM 18SINGRAHA@GMAIL.COM SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. SKYLAR INGRAHAM 18SINGRAHA@GMAIL.COM SELF SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
364 2021-01-14 13:46 Anonymous (not verified) 173.31.147.225 JMAHER LLC Limited Liability Company 907 4TH AVE SPENCER, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-14 JUSTIN MAHER CCRIOWA@GMAIL.COM SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. JUSTIN MAHER CCRIOWA@GMAIL.COM SELF SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
475 2021-04-13 19:19 Anonymous (not verified) 173.31.147.225 COAST TO COAST MILLWRIGHT LLC Limited Liability Company 2909 HWY 71 AND 9 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-05 JANIE CANTU JOEL@WALKERINSURANCEIA.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. JANIE CANTU janiecantu433@outlook.com SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
476 2021-04-13 19:23 Anonymous (not verified) 173.31.147.225 COAST TO COAST MILLWRIGHT LLC Limited Liability Company 2909 HWY 71 AND 9 SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-04-05 ADALBERTO CANTU JOEL@WALKERINSURANCEIA.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. ADALBERTO CANTU janiecantu433@outlook.com SELF-MEMBER SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
498 2021-04-27 12:54 Anonymous (not verified) 173.31.147.225 TYREL KINKADE DBA: KINKADE CONSTRUCTION Proprietorship 2289 165TH ST UNIT 10D I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 TYREL KINKADE hogtyd97@yahoo.com SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. TYREL KINKADE JOEL@WALKERINSURANCEIA.COM SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET 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
766 2021-11-22 16:19 Anonymous (not verified) 63.229.189.35 Tribal Tile, LLC Limited Liability Company 1402 Ithaca Ave, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Josh Loerzel joshloerzel@gmail.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Josh Loerzel joshloerzel@gmail.com Self SPIRIT LAKE Dickinson IA Abigail Miles Alex Miles Signed
767 2021-11-22 16:42 Anonymous (not verified) 63.229.189.35 Lakes Custom Bath Proprietorship 3721 Ithaca Avenue, Spirit Lake IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Rick Dykshoorn abigail@rickmilesartisans.com SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Rick Dykshoorn abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
768 2021-11-22 16:53 Anonymous (not verified) 63.229.189.35 Jeff Luchtel Painting Proprietorship PO Box 225, Milford, IA 51351-0225 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Jeff Luchtel jluchtel@gmail.com Milford Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Jeff Luchtel abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
769 2021-11-22 17:13 Anonymous (not verified) 63.229.189.35 Jeff Johnson Proprietorship 3114 Keokuk Ave, Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Jeff Johnson juliejeff1994@yahoo.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Jeff Johnson abigail@rickmilesartisans.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
800 2021-12-15 16:50 Anonymous (not verified) 63.229.189.35 CT Home Services Limited Liability Company 706 Jackson Avenue, Spirit lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-15 Mike Oolman mikecthome@gmail.com Spirit lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Mike Oolman mikecthome@gmail.com Self Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed
1126 2022-05-25 12:06 Anonymous (not verified) 63.229.189.35 Frame 2 Finish LLC Limited Liability Company 25620 164th St Spirit lake, IA51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-05 Chris Miller frame2finish3550@gmail.com Spirit Lake Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Chris Miller frame2finish3550@gmail.com Self SPIRIT LAKE Dickinson Iowa Abigail Miles Alex Miles Signed
1476 2023-02-22 12:23 Anonymous (not verified) 94.188.205.174 KARL INGWERSEN Proprietorship 2716 FRANCIS SITES DR SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-22 KARL INGWERSEN KARL58INGWERSEN@GMAIL.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. KARL INGWERSEN KARL58INGWERSEN@GMAIL.COM SELF SPIRIT LAKE DICKSINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1626 2023-05-05 11:16 Anonymous (not verified) 94.188.205.166 I HAWK BUILDERS LLC Limited Liability Company 1417 INDIAN HILLS DR SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-05 BEN BRANT babrant99@yahoo.com SPIRIT LAKE DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. BEN BRANT joel@walkerinsuranceia.com SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1850 2023-09-20 16:28 Anonymous (not verified) 94.188.207.225 JB DOCK SERVICE Limited Liability Company 1313 34TH ST SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-20 JONATHON BRUNSVOLD jbdockservice@gmail.com SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JONATHON BRUNSVOLD jbdockservice@gmail.com SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
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
1977 2024-01-05 13:25 Anonymous (not verified) 94.188.207.228 BOYOK BUILDS, LLC Limited Liability Company 25395 140TH 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. 2024-01-04 VITALE BOYOK BOYOK68@GMAIL.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. VITALE BOYOK BOYOK68@GMAIL.COM SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1978 2024-01-08 13:28 Anonymous (not verified) 94.188.205.167 TYREL GIBSON Proprietorship 2004 CHICAGO 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. 2024-01-08 TYREL GIBSON TY11TEKFALL@GMAIL.COM SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. TYREL GIBSON TY11TEKFALL@GMAIL.COM SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
2115 2024-03-26 14:53 Anonymous (not verified) 94.188.207.223 DICKINSON COUNTY CLEANING AND MAINTENANCE, LLC Limited Liability Company 414 19TH ST PO BOX 182 SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-26 LISA ARROWOOD lisa.arrowood1126@gmail.com SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. LISA ARROWOOD lisa.arrowood1126@gmail.com SELF SPIRIT LAKE DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
763 2021-11-22 12:32 Anonymous (not verified) 63.229.189.35 Adam Dotson Tiling Proprietorship 324 E 14th Street, Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Adam Dotson adamdotson1975@gmail.com Spencer Clay Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Adam Dotson adamdotson1975@gmail.com Self Spencer Clay Iowa Abigail Miles Alex Miles Signed
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
772 2021-11-23 10:13 Anonymous (not verified) 63.229.189.35 Hubbards Cupboards Proprietorship 713 2nd Ave SW, Spencer, IA 51301-5603 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-23 James Hubbard abigail@rickmilesartisans.com Spencer Clay Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. James Hubbard abigail@rickmilesartisans.com Self Spencer Clay Iowa Abigail Miles Alex Miles Signed
1306 2022-09-13 15:50 Anonymous (not verified) 96.31.1.206 LUCIO PAINTING Proprietorship 818 W 4TH ST SPENCER, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-06 LUCIO PENA joel@walkerinsuranceia.com SPENCER CLAY IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. LUCIO PENA joel@walkerinsuranceia.com SELF SPENCER CLAY IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
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
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
2030 2024-02-07 10:10 Anonymous (not verified) 94.188.207.227 Jason Jacobs Proprietorship 115 West 7th St., Suite 1W, Spencer, IA 51301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 Jason Jacobs jason.jacobs@thrivent.com Spencer Clay Iowa Brad Bernardy Emily Jacobs Signed (1) The employer does not elect the employers’ liability coverage. Jason Jacobs jason.jacobs@thrivent.com Self Spencer Clay Iowa Brad Bernardy Emily Jacobs Signed
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
287 2020-10-21 18:35 Anonymous (not verified) 173.218.73.44 Bilyeu Underground LLC Limited Liability Company 1136 W. Irene Ct. Nixa, MO 65714 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Gary George Bilyeu garygb1990@gmail.com Sparta Christian Missouri Daniel Bilyeu Chad Anthony Charles Signed (1) The employer does not elect the employers’ liability coverage. Gary George Bilyeu garygb1990@gmail.com Owner Sparta Christian Missouri Chad Anthony Charles Daniel Bilyeu Signed
1509 2023-03-09 10:39 Anonymous (not verified) 94.188.207.227 Andres Barboza Limited Liability Company 329 West 31 St South Sioux city ne 68776 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-09 Andres Barboza barboza79@yahoo.com South Sioux City Nebraska United States Jaime Gutierrez Gerardo ibarra Signed (1) The employer does not elect the employers’ liability coverage. Andres Barboza barboza79@yahoo.com Owner South Sioux City Nebraska United States Jaime Gutierrez Gerardo ibarra Signed
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
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
1365 2022-11-09 15:42 Anonymous (not verified) 173.189.165.11 Todd Nelson DBA: TSTR Custom Woodworking Proprietorship 625 West Sovers St, 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. 2022-11-09 Todd Nelson tstr4040@gmail.com Solon Johnson Iowa Jeff Bair-Agent Ryan Hajek Signed (1) The employer does not elect the employers’ liability coverage. Todd Nelson tstr4040@gmail.com Owner/Manager Solon Johnson IA Jeff Bair Ryan Hajek Signed
1635 2023-05-10 07:25 Anonymous (not verified) 94.188.205.166 Chris Hay Proprietorship 4911 Sutliff Rd Solon, IA 52333 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-10 Christopher A Hay hay2u2@windstream.net Solon Johnson Iowa Brad Bower Kirk Strunk Signed (1) The employer does not elect the employers’ liability coverage. Christopher Hay hay2u2@windstream.net Self Solon Johnson Iowa Brad Bower Kirk Strunk Signed
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
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
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
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
109 2020-04-03 12:42 Anonymous (not verified) 174.219.131.25 Upright Construction Limited Liability Company 2514 S norton ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-03 Maurice Williams uprightway@mail.com Sioux Falls Minihaha SD Ashley Williams Chris Johnson Signed (1) The employer does not elect the employers’ liability coverage. Maurice Williams uprightway@mail.com Owner Sioux Falls Minihaha SD Ashley Williams Chris Johnson Signed
807 2021-12-20 09:30 Anonymous (not verified) 63.153.145.38 Jerry Ollerich Trucking Proprietorship 46884 267th Street Sioux Falls SD 57106 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-20 Jerald William Ollerich jeanollerich@yahoo.com Sioux Falls Minnehaha SD James K. Ollerich Joanne K. Berg Signed (1) The employer does not elect the employers’ liability coverage. Jean Staebell Ollerich jeanollerich@yahoo.com Wife/manager Sioux Falls Minnehaha SD James K. Ollerich Joanne K. Berg Signed
1498 2023-03-07 11:20 Anonymous (not verified) 94.188.205.176 KATEN LLC Limited Liability Company 5100 S ASH GROVE AVE SIOUX FALLS, SD 57108 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 MIKE KLEIN joel@walkerinsuranceia.com SIOUX FALLS MINNEHAHA SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. MIKE KLEIN JOEL@WALKERINSURANCEIA.COM SELF SIOUX FALLS MINNEHAHA SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1500 2023-03-07 11:22 Anonymous (not verified) 94.188.205.177 KATEN LLC Limited Liability Company 5100 S ASH GROVE AVE SIOUX FALLS, SD, 57108 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-27 MICHELLE KATEN JOEL@WALKERINSURANCEIA.COM SIOUX FALLS MINNEHAHA SD JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. MICHELE KATEN JOEL@WALKERINSURANCEIA.COM SELF SIOUX FALLS MINNEHAHA SD JOSEPH THOMAS LORINGJ JENNIFER JANET YOUNGWIRTH Signed
2029 2024-02-07 09:51 Anonymous (not verified) 94.188.207.223 Jorge Llanos Proprietorship 3304 Le Mesa Way, South Sioux City, NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 Jorge Llanos jorge.llanos123708@gmail.com South Sioux City Dakota Nebraska Jordan Nisiewicz Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Monica Acosta macosta@leafhome.com Recruiter Sioux Falls Minnehaha South Dakota Cody Dunbar Jordan Nisiewicz Signed
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
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
266 2020-09-21 18:08 Anonymous (not verified) 174.126.94.77 Club Fantasy Inc. Limited Liability Company P.O. Box 5115 Sioux City Iowa 51102 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-21 Curtis A. Behr cacbehr@aol.com Sioux City Woodbury Iowa Carter Vahle Dawn Meyer Signed (1) The employer does not elect the employers’ liability coverage. Curtis A. Behr cacbehr@aol.com Self Sioux City Woodbury Iowa Carter Vahle Dawn Meyer Signed
314 2020-11-13 10:18 Anonymous (not verified) 66.172.192.197 Helaine W. Sherman Trust Proprietorship P.O. Box 717, Sioux City, Iowa 51102 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-13 Helaine W. Sherman Trust, A.F. Baron, Trustee afbaron@baronsar.com Sioux City Woodbury Iowa Joni L. Stieneke Gregory N. Lohr Signed (1) The employer does not elect the employers’ liability coverage. Helaine W. Sherman Trust, A.F. Baron, Trustee afbaron@baronsar.com Trustee of Trust Sioux City Woodbury Iowa Joni L. Stieneke Gregory N. Lohr Signed
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
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
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
654 2021-09-24 15:08 Anonymous (not verified) 199.247.64.87 Steve Porter DBA Precision Striping Proprietorship 408 Embassy Ct. Sergeant Bluff, IA 51054 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-23 Steve Porter steve.porter2710@gmail.com Sergeant Bluff Woodbury Iowa Josh Nichols Steve Porter Signed (1) The employer does not elect the employers’ liability coverage. Jana Reich JNeuzil@reichpainting.com Office Manager Sioux City Woodbury Iowa Josh Nichols Steve Porter Signed
774 2021-11-29 12:28 Anonymous (not verified) 174.198.82.208 Demetrio's Construction Proprietorship 2018 Heights Ave Sioux City, IA 51104 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-29 Guillermo Demetrio moralesdalia44@yahoo.com Sioux City Woodbury Iowa Dalia E. Morales Galvez Vanessa Topete Signed (1) The employer does not elect the employers’ liability coverage. Guillermo Demetrio moralesdalia44@yahoo.com Owner Sioux City Woodbury Iowa Dalia Morales Galvez Vanessa Topete Signed
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
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
1525 2023-03-20 15:28 Anonymous (not verified) 94.188.205.174 Valentin Saucedo Proprietorship 1811 W 5th St, 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. 2023-03-20 Valentin Saucedo sauceds20@gmail.com Sioux City Woodbury IA Jacob Goodin Kevin Small Signed (1) The employer does not elect the employers’ liability coverage. Valentin Saucedo sauceds20@gmail.com Sole Prop Sioux City Woodbury IA Jacob Goodin Kevin Small Signed
1697 2023-06-20 14:36 Anonymous (not verified) 94.188.207.225 Quick Logistics LLC Limited Liability Company 3817 Orleans Avenue, 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. 2023-06-20 Tony J Moeller quick_logistics@outlook.com Sioux City IA United States Jordan Sitzmann Cody Stultz Signed (1) The employer does not elect the employers’ liability coverage. Tony J Moeller quick_logistics@outlook.com Owner Sioux City IA United States Jordan Sitzmann Cody Stultz 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
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
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
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
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
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
6 2019-11-14 13:09 Anonymous (not verified) 69.18.10.115 Sigourney Heating and Air Conditioning LLC Limited Liability Company 106 E Washington, Sigourney Iowa 52591 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-14 Spencer A Wright officeshac@gmail.com Sigourney Keokuk Iowa Darren Diethelm Myles Miller Signed (1) The employer does not elect the employers’ liability coverage. Spencer A Wright officeshac@gmail.com Owner Sigourney Keokuk Iowa Darren Diethelm Myles Miller Signed
89 2020-03-13 12:41 Anonymous (not verified) 216.96.113.16 B’s Sweet Treats Proprietorship 123 E Marion St. Sigourney IA 52591 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-13 Brandi Wehr brndwehr54@hotmail.com Sigourney Keokuk IA Brandi Brandi Signed (1) The employer does not elect the employers’ liability coverage. Brandi Wehr brndwehr54@hotmail.com Same Sigourney Keokuk IA Brandi Brandi Signed
99 2020-03-23 16:47 Anonymous (not verified) 216.96.116.78 B’s Sweet Treats Proprietorship 21484 196th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-23 Brandi Wehr brndwehr54@hotmail.com Sigourney Keokuk IA Erik Wehr Brenda Workman Signed (1) The employer does not elect the employers’ liability coverage. Brandi Wehr brndwrhr54@hotmail.com Self Sigourney Keokuk IA Brenda Workman Erik Wehr Signed
1440 2023-02-06 14:24 Anonymous (not verified) 69.40.94.166 ESW CONSTRUCTION INC Partnership 315 hIGHWAY 22, KESWICK IA 50136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-06 ROSS SIEREN rtsieren@gmail.com KESWICK KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed (1) The employer does not elect the employers’ liability coverage. BARBARA EDMUNDSON barb@iowacropservice.com agent SIGOURNEY KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed
1441 2023-02-06 14:37 Anonymous (not verified) 69.40.94.166 ESW CONSTRUCTION INC Partnership 35 HIGHWAY 22, KESWICK IA 50136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-06 JOSHUA EDMUNDSON payten@iowacropservice.com KESWICK KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed (1) The employer does not elect the employers’ liability coverage. BARBARA EDMUNDSON barb@iowacropservice.com agent SIGOURNEY KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed
1442 2023-02-06 14:40 Anonymous (not verified) 69.40.94.166 ESW CONSTRUCTION INC Partnership 315 hIGHWAY 22, KESWICK IA 50136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-06 WENDELL WILEY rtsieren@gmail.com BLOOMFIED DAVIS IOWA JULIE WHITE REBECCA APPLEGET Signed (1) The employer does not elect the employers’ liability coverage. BARBARA EDMUNDSON barb@iowacropservice.com agent SIGOURNEY KEOKUK IOWA JULIE WHITE REBECCA APPLEGET Signed
1544 2023-03-29 16:52 Anonymous (not verified) 94.188.207.228 Live Wire Trucking Limited Liability Company 109 E Marion Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-29 Joshua Allen Moore livewiretruckingIA@gmail.com Sigourney Iowa United States Ethan Weber Dylan Miller Signed (1) The employer does not elect the employers’ liability coverage. Joshua Allen Moore livewiretruckingIA@gmail.com Owner Sigourney Iowa United States Ethan David Weber Dylan Jefferey Miller Signed
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
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
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
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
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
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
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
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
2147 2024-04-12 11:52 Anonymous (not verified) 94.188.205.166 Tri County Enterprise Partnership 5527 Crane Lane NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-12 Ken McGraw kenmcgraw1974@gmail.com Center Point IA United States bob nissen Jenny Vaske Signed (1) The employer does not elect the employers’ liability coverage. Brian Ashlock brian@tricounty-iowa.com General Manager Shellsburg IA United States bob Nissen Jenny Vaske Signed
1975 2024-01-04 15:42 Anonymous (not verified) 94.188.207.229 Blake S. Judisch Masonry LLC Limited Liability Company 510 South Fulton St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-04 Blake Judisch blakejudisch@gmail.com Shell rock Butler IA Kali Judisch Terri Thomsen Signed (1) The employer does not elect the employers’ liability coverage. Blake Judisch blalejudisch@gmail.com Owner Shell rock Butler IA Kali Judisch Terri Thomsen Signed
114 2020-04-08 10:51 Anonymous (not verified) 167.142.107.216 1959 Proprietorship 601 Country Club 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. 2020-03-23 Timothy Alan Pottebaum tpottebaum@nethtc.net SHELDON O'Brien Iowa Jill Boerta Kris Schoo Signed (1) The employer does not elect the employers’ liability coverage. Timothy Alan Pottebaum tpottebaum@nethtc.net owner SHELDON O'brien Iowa Jill Boerta Kris Schoo 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
1871 2023-10-18 10:27 Anonymous (not verified) 94.188.205.169 Derik Gonyier Proprietorship 1421 Chicago Ave, Savanna, IL 61074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-14 Derik Ray Gonyier deriknalexis121413@gmail.com Savanna Carroll IL Kyle Lee Sturtz Daryl Gonyier Signed (1) The employer does not elect the employers’ liability coverage. Derik Ray Gonyier deriknalexis121413@gmail.com Self Savanna Carroll IL Kylee Lee Daryl Eugene Gonyier Signed
1872 2023-10-18 10:59 Anonymous (not verified) 94.188.205.177 Derik Gonyier Proprietorship 1421 Chicago Ave, Savanna, IL 61074 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-14 Derik Ray Gonyier deriknalexis121413@gmail.com Savanna Carroll IL Kyle Lee Sturtz Daryl Eugene Gonyier Signed (1) The employer does not elect the employers’ liability coverage. Derik Ray Gonyier deriknalexis121413@gmail.com Self Savanna Carroll IL Kyle Lee Sturtz Daryl Eugene Gonyier Signed
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
771 2021-11-22 20:29 Anonymous (not verified) 75.162.65.250 Art Flooring LLC Limited Liability Company 1225 Emma Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-23 Antonio Rojas artfloorsllc@gmail.com 1225 Emma Ave Polk Iowa Antonio Rojas Hilda Rojas Signed (1) The employer does not elect the employers’ liability coverage. Antonio Rojas artfloorsllc@gmail.com self same as above same as above iowa Antonio Rojas Hilda Rojas Signed
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
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
930 2022-02-20 13:24 Anonymous (not verified) 174.198.77.72 2Maros Excavating Company Limited Liability Company 204 West First Street, Saint Donatus, Iowa 52071 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-20 Steve Maro 2marosmfg@gmail.com Saint Donatus Jackson Iowa Brenda McKenna Joe McKenna Signed (1) The employer does not elect the employers’ liability coverage. Steve Maro 2marosmfg@gmail.com Owner Saint Donatus Jackson Iowa Brenda McKenna Joe McKenna Signed
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
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
1869 2023-10-17 00:59 Anonymous (not verified) 94.188.207.230 Lisa's Janitorial Limited Liability Company 406 S. 10th Street Sac City, Iowa 50583 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-16 Bruce Homer bhjhomer69@gmail.com Sac City Sac Iowa Autumn Simonsen Misty Brewster Signed (1) The employer does not elect the employers’ liability coverage. Bruce Homer bhjhomer69@gmail.com Self Sac City Sac Iowa Autumn Simonsen Misty Brewster Signed
2075 2024-03-05 22:32 Anonymous (not verified) 94.188.207.225 Steve Roland Trucking LLC Limited Liability Company 2141 Wadsley Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-05 Steve Roland roland.farms@yahoo.com Sac City IA United States Caylee Hoffard Kristen Wirtjers Signed (1) The employer does not elect the employers’ liability coverage. Steve Roland roland.farms@yahoo.com Owner/Member Sac City IA United States Caylee Hoffard Kristen Wirtjers Signed
2076 2024-03-05 22:38 Anonymous (not verified) 94.188.207.229 Steve Roland Trucking LLC Limited Liability Company 2141 Wadsley Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-05 Steve Roland roland.farms@yahoo.com Sac City Sac Iowa Caylee Hoffard Kristen Wirtjers Signed (1) The employer does not elect the employers’ liability coverage. Steve Roland roland.farms@yahoo.com Owner/Member Sac City Sac Iowa Caylee Hoffard Kristen Wirtjers Signed
2114 2024-03-25 18:18 Anonymous (not verified) 94.188.207.227 Lisa V Blessington Proprietorship 411 S 10th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-25 Lisa Varie Blessington lblessington@yahoo.com Sac City Sac IA Jean Rexroat Jennifer Tovar Signed (1) The employer does not elect the employers’ liability coverage. Lisa Varie Blessington lblessington@yahoo.com Same Sac City Sac IA Jean Rexroat Jennifer Tovar Signed
1179 2022-07-05 12:21 Anonymous (not verified) 173.18.233.175 Crossline Contracting LLC Limited Liability Company 2009 Wilson Ave SW, Cedar Rapids, IA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-05 Adam Anderson crosslinecontracting319@gmail.com Ryan, IA Deleware Iowa Branden Peters Todd Philpott Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Crossline Contracting LLC crosslinecontracting319@gmail.com Self Ryan Iowa Deleware Iowa Branden Peters Todd Philpott Signed
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
106 2020-03-31 10:42 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-31 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Janice Henningsen Louise Helmke Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Janice Henningsen Louise Helmke Signed
107 2020-03-31 10:47 Anonymous (not verified) 209.152.77.101 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln ST., Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-31 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Janice Henningsen Louise Helmke Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Janice Henningsen Louise Helmke Signed
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
512 2021-05-11 13:12 Anonymous (not verified) 173.31.147.225 RUTHVEN ROCKS LLC Limited Liability Company 1205 ROLLING ST RUTHVEN IOWA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-11 JEFF CACEK JEFF@RUTHVENROCKS.COM RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JEFF CACEK joel@walkerinsuranceia.com MEMBER RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
513 2021-05-11 13:14 Anonymous (not verified) 173.31.147.225 RUTHVEN ROCKS LLC Limited Liability Company 1205 ROLLING ST RUTHVEN IOWA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-11 KEITH CACEK KEITH@RUTHVENROCKS.COM RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. KEITH CACEK joel@walkerinsuranceia.com MEMBER RUTHVEN PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
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
1894 2023-11-03 10:02 Anonymous (not verified) 94.188.205.167 ASHLEY QUAIL DBA: RUSTIC ROOTS SALON Proprietorship 33596 SCHANY DR, RUTHVEN, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-03 ASHLEY QUAIL ashley-mazzanti@hotmail.com RUTHVEN PALO ALTO IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ASHLEY QUAIL ashley-mazzanti@hotmail.com SELF RUTHVEN PALO ALTO IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
2140 2024-04-09 09:28 Anonymous (not verified) 94.188.205.175 Bart Fuller& James Fuller DBA Fuller & Sons Partnership 1302 Lincoln Street Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-09 Bart Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. Bart Fuller goffins@ruthventel.com Partner Ruthven PAlo Alto Iowa Kathryn Kelley Janice Henningsen Signed
2141 2024-04-09 09:34 Anonymous (not verified) 94.188.205.177 Bart Fuller & James Fuller DBA Fuller & Sons Partnership 1302 Lincoln Street Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-09 James Fuller goffins@ruthventel.com Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed
2142 2024-04-09 09:39 Anonymous (not verified) 94.188.205.167 Bart Fuller & james Fuller DBA Fuller & Sons Partnership 1302 Lincoln Street Ruthven, IA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-09 James Fuller goffins@ruthventel.com Ruthven Pal Alto Iowa Kathryn Kelley Janice Henningsen Signed (1) The employer does not elect the employers’ liability coverage. James Fuller goffins@ruthventel.com Partner Ruthven Palo Alto Iowa Kathryn Kelley Janice Henningsen Signed
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
230 2020-08-13 16:59 Anonymous (not verified) 174.217.21.76 Aaron Gilbert Proprietorship 11864 W 125th St S, Runnells, IA 50237 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-13 Aaron Michael Gilbert gilbertinpc@msn.com Runnells Jasper Iowa Bob Coluzzi Mitch Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Aaron Michael Gilbert gilbertinpc@msn.com Same person Runnells Jasper Iowa Bob Coluzzi Mitch Coluzzi Signed
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
1086 2022-05-03 12:32 Anonymous (not verified) 173.31.148.43 SHAWN BAIRD Proprietorship PO BOX 44 307 MEADOW ST ROYAL, IA 51357 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-02 SHAWN BAIRD FLOORMAN3872@GMAIL.COM ROYAL CLAY IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. SHAWN BAIRD FLOORMAN3872@GMAIL.COM SELF ROYAL CLAY IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
1119 2022-05-18 11:51 Anonymous (not verified) 104.201.75.222 Gentry Hardware inc. Partnership 308 5th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-18 Nathan Dwaine Gentry gentrynathan@hotmail.com Rockwellcity Calhoun Iowa Emily Bethann Gentry Amanda Margaret Albee Signed (1) The employer does not elect the employers’ liability coverage. Nathan Dwaine Gentry gentrynathan@hotmail.com Owner Rockwellcity Calhoun Iowa Emily Bethann Gentry Amanda Margaret Albee Signed
1139 2022-06-02 08:49 Anonymous (not verified) 174.198.67.34 Gentry Hardware Incorporated Partnership 308 5th Street; Rockwell City, IA 50579 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-02 Emily Gentry emilygentry1127@gmail.com Rockwell City Calhoun IA Ben Rand Karie Knouf Signed (1) The employer does not elect the employers’ liability coverage. Emily Gentry emilygentry1127@gmail.com Owner Rockwell City Calhoun IA Ben Rand Karie Knouf Signed
2059 2024-02-27 11:44 Anonymous (not verified) 94.188.205.169 Dowdey Construction LLC Limited Liability Company 1010 19th Ave - Rock Valley, IA 51247 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-27 Nicholas Allen Dowdey nddowdey@hotmail.com Rock Valley Sioux Iowa Deidre Dawn Dowdey Alexander C Koedam Signed (1) The employer does not elect the employers’ liability coverage. Nicholas Allen Dowdey nddowdey@hotmail.com Self Rock Valley Sioux Iowa Deidre Dawn Dowdey Alexander C Koedam Signed
41 2020-01-20 14:26 Anonymous (not verified) 173.24.181.211 BARBARA HOOGEVEEN Proprietorship 304 MILL POND RD, ROCK RAPIDS, IA 51246 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-20 BARBARA HOOGEVEEN MCGILLH@MTCNET.NET ROCK RAPIDS LYON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. BARABARA HOOGEVEEN MCGILLH@MTCNET.NET OWNER ROCK RAPIDS LYON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
1580 2023-04-17 20:22 Anonymous (not verified) 94.188.205.167 Lance Van Der weerd Limited Liability Company 909 S Adams Street Rock Rapids IA 51246 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-17 Lance Van Der Weerd enterprisesvdw@gmail.com Rock Rapids IA United States Brittany Van Der Weerd Todd Mienerts Signed (1) The employer does not elect the employers’ liability coverage. Lance Van Der Weerd enterprisesvdw@gmail.com Myself Rock Rapids Lyon Iowa Brittany Van Der Weerd Todd Mienerts Signed
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
1754 2023-07-19 08:52 Anonymous (not verified) 94.188.207.224 Dustin Scoggins Limited Liability Company 1723 19th ave rock island Illinois I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-19 Dustin Shane Scoggins dscoggins625@gmail.com Rock island Rock island county Illinois Emily Smith-Scoggins Emily Smith-Scoggins Signed (1) The employer does not elect the employers’ liability coverage. Dustin Shane Scoggins dscoggins625@gmail.com Self Rock island Rock island county Illinois Emily Smith-Scoggins Emily Smith-Scoggins Signed
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
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
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
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
488 2021-04-20 13:42 Anonymous (not verified) 69.63.16.2 STC Construction LLC Limited Liability Company 329 Sycamore St, Riverside, IA 52327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-20 Sean Crane stc0241@gmail.com Riverside Washington Iowa Carol Glass Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Sean Crane stc0241@gmail.com Managing Member Riverside Washingon Iowa Carol Glass Dyan Kriener Signed
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
1545 2023-03-29 20:15 Anonymous (not verified) 94.188.205.176 Leaf Filter LLC Limited Liability Company 1595 georgetown road hudson ohio 44236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-29 Benjamin Joseph Truitt Bjt1228@yahoo.com Springville Linn Iowa Benjamin Joseph Truitt Jordan Nisiewiczi Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewiczi jnisiewicz@leafhome.com Regional field recruiter 2 Riverside Gallatin Montana Benjamin Joseph Truitt Jordan Nisiewiczi Signed
1643 2023-05-12 07:56 Anonymous (not verified) 94.188.205.169 Smooth Finish Drywall Proprietorship 3111 115th Riverside, IA 52327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-12 Seth T Mize II stmize@hotmail.com Riverside Washington Iowa Chris Hay Brad Bower Signed (1) The employer does not elect the employers’ liability coverage. Seth T Mize II stmize@hotmail.com Self Riverside Washington Iowa Chris Hay Brad Bower Signed
1644 2023-05-12 07:59 Anonymous (not verified) 94.188.205.176 Blue Ribbon Drywall Proprietorship 3025 Peaceful Dr Riverside, IA 52327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-12 Seth Mize Sr stmize@hotmail.com Riverside Washington Iowa Brad Bower Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Seth Mize Sr stmize@hotmail.com Self Riverside Washington Iowa Brad Bower Chris Hay Signed
2149 2024-04-15 11:20 Anonymous (not verified) 94.188.207.224 Grady Yeggy Proprietorship 211 3rd St. Riverside, IA 52327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-11 Grady S Yeggy kellylanz1967@gmail.com Riverside IA United States Amanda Yeggy Leah Evans Signed (1) The employer does not elect the employers’ liability coverage. Grady S Yeggy kellylanz1967@gmail.com Self Riverside IA United States Amanda Yeggy Leah Yeggy Signed
1348 2022-10-28 10:19 Anonymous (not verified) 208.38.230.122 HALSEY'S HOME IMPROVEMENTS, LLC Limited Liability Company 126 SYCAMORE LANE, RIVERDALE, IOWA 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-28 MONTY RAY HALSEY crickstic@gmail.com RIVERDALE SCOTT IA DARRELL MACHALEK JR. MATTHEW DAVISON Signed (1) The employer does not elect the employers’ liability coverage. MONTY HALSEY crickstic@gmail.com SELF RIVERDALE SCOTT IA DARRELL MACHALEK JR. MATTHEW DAVISON Signed
1489 2023-02-28 16:06 Anonymous (not verified) 94.188.207.228 Nate's Tractor LLC Limited Liability Company 11939 birch Ave Riceville, IA 50466 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-28 Nathan Fox nate@natestractor.com Riceville Howard Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Nathan Fox nate@natestractor.com Member Riceville Howard Iowa Chris Fye Darrel Elsbernd Signed
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
2201 2024-05-06 10:42 Anonymous (not verified) 94.188.207.226 Trent Hatlen Proprietorship 1042 490th Street, Rembrandt, IA 50576 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Trent Hatlen trentgotti@yahoo.com Rembrandt Buena Vista Iowa Jared Brashears Katie Gunkelman Signed (1) The employer does not elect the employers’ liability coverage. Trent Hatlen trentgotti@yahoo.com Owner Rembrandt Buena Vista Iowa Jared Brashears Katie Gunkelman 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
1003 2022-03-23 13:06 Anonymous (not verified) 24.149.3.190 Thomas Wedmore Proprietorship 200 State St, Ste 202G, 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. 2022-03-23 Thomas Wedmore twedmore@phillipsstafford.com Cedar Falls IA United States Bradley Phillips Joshua Stafford Signed (1) The employer does not elect the employers’ liability coverage. Thomas Wedmore twedmore@phillipsstafford.com Self Reinbeck Grundy IA Bradley Phillips Joshua Stafford Signed
1335 2022-10-17 11:32 Anonymous (not verified) 71.39.227.238 PELZER AG LLC Limited Liability Company 16864 280TH ST, REDFIELD, IA 50233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-17 MATT PELZER MPELZERFARMS@GMAIL.COM REDFIELD DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed (1) The employer does not elect the employers’ liability coverage. MATT PELZER MPELZERFARMS@GMAIL.COM PRESIDENT REDFIELD DALLAS IOWA ABBEY LUELLEN DON RICHARDSON Signed
1448 2023-02-10 16:55 Anonymous (not verified) 94.188.205.177 Marks Nursery LLC Limited Liability Company 15008 310th Trl, Redfield, IA 50233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-10 Susan L Jones sljoines026@gmail.com Redfield Dallas Iowa Douglas Jones Caitlin Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Donald Richardson DonR@phillipsassociatesins.net Agent Redfield Dallas Iowa Douglas Zimmerman Caitlin Zimmerman Signed
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
1895 2023-11-03 12:21 Anonymous (not verified) 94.188.207.227 Oxbo LLC Limited Liability Company 2528 Evergreen Ave. Red Oak, IA 51566 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-03 Mettra Sperling sperlingrose66@gmail.com Red Oak Montgomery IA Chantal Sperling Derek Penry Signed (1) The employer does not elect the employers’ liability coverage. Mettra Sperling sperlingrose66@gmail.com Self Red Oak Montgomery IA Chantal Sperling Derek Penry Signed
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
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
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
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
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
1456 2023-02-15 13:12 Anonymous (not verified) 94.188.205.168 Bloodgood construction services Proprietorship 4422 happy trail prole ia 50229 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Alan Dean bloodgood alanbloodgood@gmail.com Prole Warren Ia Derek bloodgood Albert bloodgood Signed (1) The employer does not elect the employers’ liability coverage. Bloodgood construction services alanbloodgood@gmail.com Self Prole Warren Ia Derek bloodgood Albert bloodgood Signed
1617 2023-04-28 08:26 Anonymous (not verified) 94.188.207.230 JD Transport Limited Liability Company 24940 247th ave Princeton Iowa 52768 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-28 Jacob Dies jacobdiestransport@gmail.com Princeton Scott Iowa Eric Dies Karri Dies Signed (1) The employer does not elect the employers’ liability coverage. Jacob Dies Jacobdiestransport@gmail.com Self Princeton Scott Iowa Eric Dies Karri Dies Signed
1783 2023-08-04 10:17 Anonymous (not verified) 94.188.207.229 Lundin trucking llc Limited Liability Company 322 w wilson street preston iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-04 Devin dallas lundin devinlundin@hotmail.com Preston Jackson Iowa Kathy kilburg Greg kilburg Signed (1) The employer does not elect the employers’ liability coverage. Devin lundin devinlundin@hotmail.com Owner Preston Jackson Iowa Kathy kilburg Greg kilburg Signed
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
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
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
737 2021-11-11 14:33 Anonymous (not verified) 72.13.16.172 BADGER COUNTRY TRUCKING LLC Limited Liability Company 3877 US HWY 35 AND 61 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-13 BADGER COUNTRY TRUCKING LLC dave@allseasonstrucking.com POTOSI GRANT WI Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. BADGER COUNTRY TRUCKING LLC dave@allseasonstrucking.com PRESIDENT POTOSI GRANT WI Dave Neuwohner BEN MOYER Signed
740 2021-11-11 14:54 Anonymous (not verified) 72.13.16.172 LECHTENBERG TRUCKING LLC Limited Liability Company 10185 HWY 18 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 LECHTENBERG TRUCKING LLC dave@allseasonstrucking.com POSTVILLE CLAYTON IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. LECHTENBERG TRUCKING LLC dave@allseasonstrucking.com PRESIDENT POSTVILLE CLAYTON IA Dave Neuwohner BEN MOYER Signed
442 2021-03-22 12:14 Anonymous (not verified) 149.20.235.228 Tim Bruck Construction Inc. Proprietorship 348 Highway 44 Rd. Porstmouth, IA 51565 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-22 Timothy Richard Bruck timrbruck@gmail.com Portsmouth Shelby Iowa Heath Ryan Stein Faith Nicole Bruck Signed (1) The employer does not elect the employers’ liability coverage. Tim Richard Bruck timrbruck@gmail.com Self Portsmouth Shelby Iowa Heath Ryan Stein Faith Nicole Bruck 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
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
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
544 2021-06-21 16:10 Anonymous (not verified) 97.125.169.60 Tenant Improvement Services, LLC Limited Liability Company 3011 Justin Drive, Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-21 Jake Etter jake@tenantimprovemetnsiowa.com Polk City Polk Iowa Ashley Overton Aylah Etter Signed (1) The employer does not elect the employers’ liability coverage. Jake Etter jake@tenantimprovementsiowa.com Member Polk City Polk Iowa Ashley Overton Aylah Etter Signed
881 2022-02-02 09:39 Anonymous (not verified) 173.215.80.185 Tree & Forestry Equipment Inc Partnership 201 Deer Haven St., Polk City, IA 50226 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-02 Deborah Frye deb@treeandforestry.com Polk City Polk IA Joshua Frye Phoebe Trent Signed (1) The employer does not elect the employers’ liability coverage. Deborah Frye deb@treeandforestry.com Self Polk City Polk IA Joshua Frye Phoebe Trent Signed
1752 2023-07-17 13:21 Anonymous (not verified) 94.188.207.225 GPS Construction Limited Liability Company 920 Wolf Creek Polk City, IA 50226 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-07-17 Gregory Schultz gregpschultz@gmail.com POLK CITY IA United States Dillon Temple Derek Temple Signed (1) The employer does not elect the employers’ liability coverage. Gregory Schultz gregpschultz@gmail.com Owner POLK CITY IA United States Dillon Temple Derek Temple Signed
1947 2023-12-07 16:01 Anonymous (not verified) 94.188.205.176 Reinier Construction LLC Limited Liability Company 1406 Linden Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-07 David J Reinier reinierconst@aol.com Des Moines Polk IA PEGGY A ROHDE Douglas E Rohde Signed (1) The employer does not elect the employers’ liability coverage. PEGGY A ROHDE dnprohde@msn.com Bookkeeper Polk City Polk IA Douglas E Rohde Stacie L Miller Signed
2204 2024-05-06 18:56 Anonymous (not verified) 94.188.205.168 Jim saukko Proprietorship 13232 nw 30 th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-05 Jim Saukko saukkogt500@gmail.com Polk city IA United States Dawn brown Kirk moser Signed (1) The employer does not elect the employers’ liability coverage. Jim Saukko saukkogt500@gmail.com Self Polk city IA IA Dawn brown Kirk moser Signed
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
905 2022-02-08 10:23 Anonymous (not verified) 74.115.101.41 Triple TTT Transport, LLC Limited Liability Company 307 7th Avenue SE, Belmond, IA 50541 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-08 Clint C Christians christiansclint0@gmail.com Pocahontas pocahontas Iowa Dale R Eng Cheri Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Clint Christians christiansclint0@gmail.com Partner Pocahontas Pocahontas Iowa Dale Eng Cheri Zimmerman Signed
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
1890 2023-11-01 19:22 Anonymous (not verified) 94.188.207.228 JACK SCHADE Proprietorship 911 Broad St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-01 jack allan schade jackschade@yahoo.com Plymouth IA IA jack allan schade jack allan schade Signed (1) The employer does not elect the employers’ liability coverage. jack allan schade jackschade@yahoo.com self Plymouth IA IA jack allan schade jack allan schade Signed
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
1572 2023-04-13 11:12 Anonymous (not verified) 94.188.205.167 CK Trucking Proprietorship 24497 Hayes Street, Pleasantville, Iowa 50225 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-13 Craig Kooyman dmsstumpguy@yahoo.com Pleasantville IA IA Chad Randleman James Jordan Signed (1) The employer does not elect the employers’ liability coverage. Craig Kooyman dmsstumpguy@yahoo.com Owner Pleasantville Warren IA Chad Randleman James Jordan Signed
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
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
343 2020-12-28 10:46 Anonymous (not verified) 173.18.204.82 Shelly Hildebrand Proprietorship 424 E 44th St Pleasant Hill Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-28 Shelly Hildebrand centraliowacleaningservice@mediacombb.net Pleasant Hill Polk Iowa Cathy Stevens Bailey Hildebrand Signed (1) The employer does not elect the employers’ liability coverage. Shelly Hildebrand centraliowacleaningservice@mediacombb.net Self Pleasant Hill Polk Iowa Cathy Stevens Bailey Hildebrand Signed
543 2021-06-16 12:49 Anonymous (not verified) 174.250.64.145 McCulloch Construction LLC Limited Liability Company 2590 SE 68TH ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-01 Scott Rouse MCCULLOCHCONSTRUCTION78@GMAIL.COM PLEASANT HILL Polk IA Joel Rouse Shonna Rouse Signed (1) The employer does not elect the employers’ liability coverage. Scott Rouse MCCULLOCHCONSTRUCTION78@GMAIL.COM Owner PLEASANT HILL Polk IA Joel Rouse Shonna Rouse Signed
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
902 2022-02-07 11:53 Anonymous (not verified) 65.144.174.26 Donald Gardner Jr. Proprietorship 625 NE 72nd Street, Pleasant Hill, Iowa 50327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-07 Donald Gardner, Jr. dnagardner95@yahoo.com Pleasant Hill Polk Iowa Andrew West Braden Collins Signed (1) The employer does not elect the employers’ liability coverage. Donald Gardner, Jr. dnagardner95@yahoo.com Owner Pleasant Hill Polk Iowa Andrew West Braden Collins Signed
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
1377 2022-11-21 13:06 Anonymous (not verified) 166.181.84.102 Leaf home solutions Proprietorship 1595 George Town road Hudson Ohio 44236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-21 Christopher da von carpenter chris.carpenter9595@icloud.com Pleasant hill Polk Iowa Clara Francis carpenter Thrinadh gutta Signed (1) The employer does not elect the employers’ liability coverage. Christopher da von carpenter chris.carpenter9595@icloud.com Self Pleasant hill Polk Iowa Clara Francis carpenter Thrinadh gutta Signed
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
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
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
2218 2024-05-09 16:20 Anonymous (not verified) 94.188.205.167 Brenda Riseley Proprietorship 2265 Copper Wynd Drive, Pleasant Hill Iowa 50327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-09 Brenda Riseley riseleybrenda@gmail.com Pleasant Hill IA United States Brenda Riseley Brenda Riseley Signed (1) The employer does not elect the employers’ liability coverage. Brenda Riseley riseleybrenda@gmail.com Self Pleasant Hill IA United States David Bottino Aubrey Stith Signed
910 2022-02-10 15:46 Anonymous (not verified) 184.100.98.101 Carich properties Proprietorship 6842 Fawn Rd. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-10 Chris Richard ticketbarandgrill@gmail.com Platteville Grant Wisconsin Allison Richard Melodee Richard Signed (1) The employer does not elect the employers’ liability coverage. Chris Richard ticketbarandgrill@gmail.com Owner Platteville Grant Wisconsin Allison Richard Melodee Richard Signed
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
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
1423 2023-01-16 14:03 Anonymous (not verified) 173.224.19.200 Hoofin-It Proprietorship 86148 537th Ave. Plainview, NE 68769 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-16 Chase Terrill terrill365@gmail.com Pierce Pierce Nebraska Jim Aschoff Calan List Signed (1) The employer does not elect the employers’ liability coverage. Cole Aschoff aschoff_2@icloud.com Co-Owner Plainview Pierce Nebraska Jim Aschoff Calan List Signed
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
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
1650 2023-05-16 12:06 Anonymous (not verified) 94.188.207.225 R & J Transport Proprietorship 85152 US HWY 81 PIERCE NE 68767 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-16 Ray Tom Clausen III jamieleabeutler2013@gmail.com Pierce NE United States Jamie Clausen Ann Siebrandt Signed (1) The employer does not elect the employers’ liability coverage. Ray T Clausen III jamieleabeutler2013@gmail.com Owner Pierce Pierce Ne Jamie Clausen Ann Siebrandt Signed
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
1790 2023-08-08 14:32 Anonymous (not verified) 94.188.205.166 NJ CONSTRUCTION LLC Limited Liability Company 4291 30TH AVE PETERSON, IA 51047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-08 NICHOLAS JAMES JONES njconstruction2014@hotmail.com PETERSON BUENA VISTA IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. NICHOLAS JAMES JONES njconstruction2014@hotmail.com SELF PETERSON BUENA VISTA IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
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
311 2020-11-10 10:42 Anonymous (not verified) 75.162.206.98 Menz Construction, LCC Limited Liability Company 304 SW Clark Lane, Grimes, Iowa 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-10 Jeff Menz construction.menz@gmail.com Grimes Polk Iowa Janelle Menz Barb Menz Signed (1) The employer does not elect the employers’ liability coverage. David Finneseth david.finneseth@fbfs.com Agent Perry Dallas Iowa Janelle Menz Barb Menz Signed
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
805 2021-12-20 08:40 Anonymous (not verified) 65.144.174.26 TILE DECOR INC Proprietorship 1702 WEST 3RD ST PERRY, IA 50220 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-17 HUGO COJON CAMEYHUGO@GMAIL.COM PERRY DALLAS IOWA GABRIELA PEREZ NARCISO HIDALGO Signed (1) The employer does not elect the employers’ liability coverage. HUGO COJON CAMEYHUGO@GMAIL.COM OWNER PERRY DALLAS IOWA GABRIELA PEREZ NARCISO HIDALGO Signed
935 2022-02-24 09:44 Anonymous (not verified) 174.215.244.252 Cornejo Construction Limited Liability Company 419 2nd St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-24 Bulmaro Cornejo cruzcornejo4314@gmail.com Perry Dallas Iowa Jose Cruz Cornejo Andrade Brenda Espinoza Signed (1) The employer does not elect the employers’ liability coverage. Bulmaro Cornejo cruzcornejo4314@gmail.com Owner Perry Dallas Iowa Jose Cruz Cornejo Brenda Espinoza Signed
1109 2022-05-16 19:02 Anonymous (not verified) 173.20.161.18 Juan Manuel Alvarez Proprietorship 2011 1st Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-16 Juan m. Alvarez nemen01@hotmail.com Perry IA IA Ashley lynch Omar Alvarez Signed (1) The employer does not elect the employers’ liability coverage. Juan m. Alvarez nemen01@hotmail.com Juan Perry IA IA Ashley lynch Omar Alvarez Signed
1380 2022-11-26 07:41 Anonymous (not verified) 173.17.229.18 M&M Construction LLC Limited Liability Company 32785 Homestead Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-23 Amparo Yamilet Menendez Gonzalez menendez.amparo@yahoo.com Granger Dalles center United States Carla Diaz Jesus Lopez Signed (1) The employer does not elect the employers’ liability coverage. Gerardo Alvarado bariel578@gmail.com Employee Perry IA United States Carla Diaz Jesus lopez Signed
1589 2023-04-20 12:57 Anonymous (not verified) 94.188.205.167 Grace Flooring Proprietorship 2001 W 2nd Street perry, Iowa 50220 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-20 Ryan Michael Tool GraceFlooring0@gmail.com Perry Dallas IA Jennifer Lynn Tool Shane Workman Signed (1) The employer does not elect the employers’ liability coverage. Grace Flooring GraceFlooring0@gmail.com Owner Perry Dallas IA Jennifer Tool Shane workman Signed
1708 2023-06-25 15:10 Anonymous (not verified) 94.188.207.228 Lopez concrete Limited Liability Company 2009 otley ave perry Ia 50220 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-25 Erick Lopez lopez1concrete@gmail.com Perry Dallas IA Ever tobar. Elba alejandro Signed (1) The employer does not elect the employers’ liability coverage. Erick lopez lopez1concreto@gmail.com Owner Perry Dallas IA Ever tobar Elba alejandro Signed
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
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
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
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
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
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
1475 2023-02-21 18:42 Anonymous (not verified) 94.188.207.230 Michael Goodyk Consgtruction Proprietorship 2392 Keokuk Drive Pella, Iowa. 50219 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Michael Jay Goodyk mikegoodyk@gmail.com Pella Marion Iowa Joy Ekloffe Rick Ekloffe Signed (1) The employer does not elect the employers’ liability coverage. Gorp Edwards insurance bwilliams@vangorpins.com Insurance Agent Pella Marion Iowa Joy Ekloffe Rick Ekloffe Signed
1782 2023-08-04 08:04 Anonymous (not verified) 94.188.207.229 Matt Larson Construction Limited Liability Company 1208 Hazel St. Pella, IA 50219 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-04 Matthew Mark Larson larson-m@hotmail.com Pella Marion IA Brian Huddle Jon E. Miller Signed (1) The employer does not elect the employers’ liability coverage. Jon E. Miller stmarypella@iowatelecom.net Parish Secretary Pella IOWA United States Brian Huddle Jon E. Miller Signed
688 2021-10-25 10:56 Anonymous (not verified) 75.91.173.195 Ami Westcott Proprietorship 2672 F 52 Trail Parnell, IA 52325 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-25 Ami Lynn Westcott ami.westcott@gmail.com Parmell Iowa Iowa Donald Scott Westcott Andrew Patrick Brummel Signed (1) The employer does not elect the employers’ liability coverage. Ami Lynn Westcott ami.westcott@gmail.com self Parnell Iowa Iowa Donald Scott Westcott Andrew Patrick Brummel Signed
33 2020-01-09 15:57 Anonymous (not verified) 173.28.28.57 FALCON PRIDE PROPERTIES LLC Limited Liability Company 1401 HWY 57 PARKERSBURG, IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-13 TODD THOMAS todd@wimcoach.com PARKERSBURG BUTLER IA CHAD CAMPBELL ROXANNE KOLDER Signed (1) The employer does not elect the employers’ liability coverage. TODD THOMAS todd@wimcoach.com SELF PARKERSBURG BUTLER IA CHAD CAMPBELL ROXANNE KOLDER Signed
36 2020-01-15 13:26 Anonymous (not verified) 173.28.28.57 Shirley Pepples Proprietorship 206 4th Street, Parkersburg, IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-14 Shirley Pepples cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Shirley Pepples cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
50 2020-02-03 14:55 Anonymous (not verified) 173.28.28.57 Silverleaf Capital, LLC Limited Liability Company 1606 Palmer Court, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-20 Silverleaf Capital, LLC cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Silverleaf Capital, LLC cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
51 2020-02-04 10:31 Anonymous (not verified) 173.28.28.57 Sister Style, LLC Limited Liability Company 211 3rd Street, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Lisa Ellis cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Lisa Ellis cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
52 2020-02-04 10:35 Anonymous (not verified) 173.28.28.57 Sister Style, LLC Limited Liability Company 211 3rd Street, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Amanda Jorgenson cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Amanda Jorgenson cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
54 2020-02-06 14:18 Anonymous (not verified) 173.28.28.57 Dale Hansman dba Klinkenborg Hansmann Law Office Proprietorship 1201 Hwy 57, Parkersburg, IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-14 Dale Hansmann cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Dale Hansmann cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
129 2020-04-24 15:28 Anonymous (not verified) 173.28.28.57 Michael Jansen Proprietorship 108 6th Street, Parkersburg, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-10 Michael G Jansen cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Michael G Jansen cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
160 2020-05-18 15:04 Anonymous (not verified) 173.28.28.57 Angela Scanlan Proprietorship 26436 320th Street, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-28 Angela Scanlan cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Angela Scanlan cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
185 2020-06-12 14:50 Anonymous (not verified) 173.28.28.57 Aaron & Eliesa Thomas Partnership 706 3rd Avenue, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-20 Aaron & Eliesa Thomas cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Aaron & Eliesa Thomas cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
215 2020-07-27 13:45 Anonymous (not verified) 173.28.28.57 Main Street Printing & Design, LLC Limited Liability Company 706 3rd Avenue, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Aaron Thomas cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Aaron Thomas cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
216 2020-07-27 13:47 Anonymous (not verified) 173.28.28.57 Main Street Printing & Design, LLC Limited Liability Company 706 3rd Avenue, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Eliesa Thomas cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Eliesa Thomas cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
307 2020-11-04 14:43 Anonymous (not verified) 50.82.130.211 ALL N DESIGNS, LLC Limited Liability Company 601 Nicklaus Drive, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-23 Aimee Allan cmins_re@mchsi.com Parkersburg Butler iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Aimee Allan cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
520 2021-05-17 10:32 Anonymous (not verified) 50.82.130.211 Madison Oldenburger Proprietorship 809 3rd Avenue, Parkersburg, IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-06 Madison Oldenburger cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Madison Oldenburger cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
525 2021-05-18 09:42 Anonymous (not verified) 50.82.130.211 Adrian Bernard Proprietorship 803 Russell Circle, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-07 Adrian Bernard cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Adrian Bernard cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Chad Campbell Signed
632 2021-09-07 13:42 Anonymous (not verified) 50.82.130.211 Thomas Mann Proprietorship 401 Miners Street, Parkersburg, 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. 2021-09-09 Thomas Mann cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Thomas Mann cmins_re@mchsi.com Self Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
847 2022-01-20 13:54 Anonymous (not verified) 50.82.130.211 Albatross Capital, LLC Limited Liability Company 28003 290th Street, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Jesse Nitcher cmins_re@mchsi.com Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Jesse Nitcher cmins_re@mchsi.com Member of LLC Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
848 2022-01-20 13:56 Anonymous (not verified) 50.82.130.211 Albatross Capital, LLC Limited Liability Company 28003 290th St., Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Chris Buseman cmins_re@mchsi.com Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Chris Buseman cmins_re@mchsi.com Member of LLC Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed
849 2022-01-20 13:58 Anonymous (not verified) 50.82.130.211 Albatross Capital, LLC Limited Liability Company 28003 290th St., Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Brandon Huisman cmins_re@mchsi.com Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Brandon Huisman cmins_re@mchsi.com Member of LLC Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed
850 2022-01-20 14:03 Anonymous (not verified) 50.82.130.211 Albatross Capital, LLC Limited Liability Company 28003 290th St., Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Justin Mehmen cmins_re@mchsi.com Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Justin Mehmen cmins_re@mchsi.com Member of LLC Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed
851 2022-01-20 14:10 Anonymous (not verified) 50.82.130.211 Albatross Capital, LLC Limited Liability Company 28003 290th St., Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Justin Mehmen cmins_re@mchsi.com Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Justin Mehmen cmins_re@mchsi.com Member of LLC Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed
995 2022-03-22 14:40 Anonymous (not verified) 50.82.130.211 Pietig Construction, LLC Limited Liability Company 302 Brookside Dr, Parkersburg, IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-09 Joel Pietig cmins_re@mchsi.com Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Joel Pietig cmins_re@mchsi.com Owner/Self Parkersburg Butler IA Chad Campbell Roxanne Kolder Signed
1403 2023-01-03 15:23 Anonymous (not verified) 173.20.50.85 Falcon Pride Properties, LLC Limited Liability Company 1401 State Highway 57, Parkersburg, IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-23 D. Jay Ellis cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. D. Jay Ellis cmins_re@mchsi.com Owner Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed
1404 2023-01-03 15:26 Anonymous (not verified) 173.20.50.85 Falcon Pride Properties, LLC Limited Liability Company 1401 State Highway 57, Parkersburg, IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-23 Todd Thomas cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Todd Thomas cmins_re@mchsi.com Owner Parkersburg Butler Iowa Chad Campbell Roxanne Kolder 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
846 2022-01-20 12:02 Anonymous (not verified) 97.107.199.129 Moval Motors LLC Limited Liability Company 3153 Joliet Ave Missouri Valley IA 51555 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-19 Michael Porter msporter8855@hotmail.com Papillion sarpy Nebraska Jon Paul Burton Scott Porter Signed (1) The employer does not elect the employers’ liability coverage. Micahel Porter mporter8855@hotmail.com secretary of Moval Papillion Sarpy Nebraska Jon Paul Bruton Scott Porter Signed
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
571 2021-07-12 09:51 Anonymous (not verified) 67.55.237.31 Steve Vogel Proprietorship 314 NE 2ND ST. Panora, Iowa 50216-2020 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-12 Steve Vogel thevogels@netins.net PANORA Guthrie United States Diana Vogel Adam Vogel Signed (1) The employer does not elect the employers’ liability coverage. Steve Vogel thevogels@netins.net Self PANORA Guthrie Iowa Diana Vogel Adam Vogel Signed
936 2022-02-25 10:47 Anonymous (not verified) 173.215.112.17 Arganbright Home Construction LLC Limited Liability Company 2251 Soldier Trail, Panora, IA 50216 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-25 David E Arganbright davearganbright@netins.net Panora Guthrie IA Cindy J Carstens Andrew Randol Signed (1) The employer does not elect the employers’ liability coverage. Christine M Arganbright chrisbia@netins.net Member Panora Guthrie IA Cindy J Carstens Andrew Randol Signed
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
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
325 2020-11-23 11:14 Anonymous (not verified) 174.198.82.169 Dan davidson Limited Liability Company 21Lincoln Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-11-22 Daniel Lee davidson unitedremodelingdd@gmail.com Palo Linn IA Daniel Lee davidson Daniel Lee davidson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Daniel Lee davidson unitedremodelingdd@gmail.com Owner Palo Linn IA Daniel Lee davidson Daniel Lee davidson Signed
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
1317 2022-09-21 15:04 Anonymous (not verified) 184.81.198.17 Mark Jagnow Proprietorship 2174 Rohret Rd SW Oxford IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-21 Mark Allen Jagnow Mark@Jagnow.com Oxford Johnson Iowa Catherine Louise Nelson Joseph Roger Titone Signed (1) The employer does not elect the employers’ liability coverage. Mark Allen Jagnow Mark@jagnow.com self Oxford Johnson Iowa Catherine Louise Nelson Joseph Roger Titone Signed
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
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
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
1399 2022-12-22 08:40 Anonymous (not verified) 45.16.156.93 Valley Five, LLC DBA L & N Docks and Lifts Limited Liability Company 9523 W 151st Ter Overland Park, KS 66221 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-22 Steven Dolezal steven.w.dolezal@gmail.com Overland Park Johnson Kansas Joan Dolezal Kelsey Dolezal Signed (1) The employer does not elect the employers’ liability coverage. Steve Dolezal steven.w.dolezal@gmail.com Owner Overland Park Johnson Kansas Joan Dolezal Kelsey Dolezal Signed
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
235 2020-08-18 13:25 Anonymous (not verified) 50.83.91.36 Tyler Abigt Proprietorship 636 Crestview Ave Ottumwa, 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. 2020-08-18 Tyler Abigt Abigtlettering@gmail.com Ottumwa Wapello Iowa Jonathan Strube Michelle Abigt Signed (1) The employer does not elect the employers’ liability coverage. Tyler Abigt Abigtlettering@gmail.com Owner Ottumwa Wapello Iowa Jonathan Strube Michelle Abigt Signed
378 2021-01-29 11:43 Anonymous (not verified) 50.82.21.136 GRAPHIX MASTERS Limited Liability Company 420 Hamilton St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-01-29 Klayton Karl Kirkpatrick klay@graphixmasters.us Ottumwa IA United States Brian Wilson Aimee Kirkpatrick Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Klayton Kirkpatrick klay@graphixmasters.us Same Ottumwa Iowa United States Brian Wilson Aimee Kirkpatrick Signed
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
1011 2022-03-28 10:25 Anonymous (not verified) 207.199.231.172 Brian Carmer Proprietorship 133 S Iowa Ave, Ottumwa, IA 52501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 Brian Carmer b_carmer@yahoo.com Ottumwa Wapello Iowa James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Brian Carmer B_Carmer@yahoo.com Self Ottumwa Wapello Iowa James Anderson Ashley Bryan Signed
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
1667 2023-05-29 22:31 Anonymous (not verified) 94.188.207.226 All J Acres Limited Liability Company 13522 120th Ave, Ottumwa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-26 Jonathan Bunt jonbunt@gmail.com Ottumwa Wapello IA James Williamson James Ash Signed (1) The employer does not elect the employers’ liability coverage. Jonathan Bunt jonbunt@gmail.com Self Ottumwa Wapello IA James Williamson James Ash Signed
605 2021-08-16 16:06 Anonymous (not verified) 67.55.155.46 COMPLETE CONSTRUCTION SERVICES LLC Limited Liability Company 718 FOX RUN I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-16 DAVID BOWER BOWERD@OSKYCSD.ORG OSKALOOSA MAHASKA IOWA JAMES MCNAUL CINDY STEVENSON GRUBB Signed (1) The employer does not elect the employers’ liability coverage. DAVID BOWER BOWERD@OSKYCSD.ORG PRESIDENT OSKALOOSA MAHASKA IOWA JAMES MCNAUL CINDY STEVENSON GRUBB Signed
843 2022-01-20 07:48 Anonymous (not verified) 207.199.230.75 Heart of Iowa Inspections LLC Limited Liability Company 2700 Highway 63 Oskaloosa, Iowa 52577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-20 Randy DeHeer rdenheer2828@gmail.com Oskaloosa Mahaska Iowa Cheryl Brown Doris Crile Signed (1) The employer does not elect the employers’ liability coverage. Randy DeHeer rdenheer2828@gmail.com self Oskaloosa Mahaska Iowa Cheryl Brown Doris Crile Signed
864 2022-01-27 12:50 Anonymous (not verified) 67.55.155.207 Chamra Farms Limited Liability Company 3031 215 th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Andy Chamra apchamra@gmail.com Rose Hill Iowa United States Steve Weller Connie VanKlootwyk Signed (1) The employer does not elect the employers’ liability coverage. Steven Weller steve.weller@insurancestationinc.com Agent OSKALOOSA Iowa United States Andy Chamra Connie Van Klootwyk Signed
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
934 2022-02-23 12:13 Anonymous (not verified) 207.199.230.75 Randy DeHeer Limited Liability Company 2700 Highway 63 Oskaloosa, Iowa 52577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-23 Randy DeHeer rdeheer2828@gmail.com Oskaloosa Mahaska Jowa Cheryl Brown Doris Crile Signed (1) The employer does not elect the employers’ liability coverage. Randy DeHeer rdeheer2828@gmail.com Self Oskaloosa Mahaska Iowa Cheryl Brown Doris Crile Signed
962 2022-03-09 16:45 Anonymous (not verified) 207.199.231.172 Thomas Whitehead Proprietorship 1602 Green St Oskaloosa, IA 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. 2022-03-09 Thomas Whitehead roctomjj@mahaska.org Oskaloosa Mahaska Iowa James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Thomas Whitehead roctomjj@mahaska.org Self Oskaloosa Mahaska Iowa James Anderson Ashley Bryan 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
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
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
1994 2024-01-23 14:35 Anonymous (not verified) 94.188.207.229 Josh Oswald Proprietorship 505 Eisenhower Rd., Osceola, IA 50213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-23 Josh Oswald jjoswald47@gmail.com Osceola Clarke Iowa Douglas Eugene Miller Elaine Lee Signed (1) The employer does not elect the employers’ liability coverage. JOSHUA OSWALD jjoswald47@gmail.com Sole Proprietor Osceola Clarke Iowa Douglas Eugene Miller Elaine Lee Signed
491 2021-04-20 15:57 Anonymous (not verified) 199.102.210.217 mjm,inc Proprietorship 32345 200th st dallas centert ia 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-20 john paul wewrner johnpwerner17@gmail.com osage michell ia carolyn lee werner amanda lee johnson Signed (1) The employer does not elect the employers’ liability coverage. johnwerner johnpwerner17@gmail.com friend osage mithell ia carolyn lee werner amanda lee johnson Signed
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
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
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
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
1472 2023-02-20 15:52 Anonymous (not verified) 94.188.207.230 C & A Fox Farms LLC Limited Liability Company 3275 Valley Ave Orchard IA 50460 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Curtis Fox sales@foxfarmsllc.com Orchard IOWA United States Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Curtis Fox sales@foxfarmsllc.com Self Orchard IOWA United States Darrel Elsbernd Chris Fye Signed
1473 2023-02-20 15:57 Anonymous (not verified) 94.188.207.224 C & A Fox Farms LLC Limited Liability Company 3275 valley Ave Orchard IA 50460 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Allen Fox sales@foxfarmsllc.com Orchard Mitchell Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Allen Fox sales@foxfarmsllc.com self Orchard Mitchell Iowa Darrel Elsbernd Chris Fye Signed
26 2020-01-04 17:23 Anonymous (not verified) 45.53.67.52 Gary De Jager Limited Liability Company 417 florida Ave NW Orange City Iowa 51041 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-04 Gary Dean De Jager mightyspear60@yahoo.com Orange City Souix Iowa Brody Dean De Jager Tyler Ray De Jager Signed (1) The employer does not elect the employers’ liability coverage. Gary Dean De Jager mightyspear60@yahoo.com owner Orange City souix Iowa Brody Dean De Jager Tyler Ray De Jager Signed
2168 2024-04-22 08:18 Anonymous (not verified) 94.188.207.228 Mattson's Floor Covering Proprietorship 2073 Sandy Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-22 Blaine Linn Mattson tmatzan99@yahoo.com Oquawka Henderson Illinois Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Blaine Mattson tmatzan22@yahoo.com owner Oquawka Henderson Illinois Cheryl Ross Larry Rheinschmidt Signed
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
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
1726 2023-07-07 18:22 Anonymous (not verified) 94.188.205.168 D&E LLC DBA Kanesville Valley Limited Liability Company P.O. Box 337 Council Bluffs, IA, 51502 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-07 Damien Joseph Shull damienshull@gmail.com Omaha Douglas Nebraska Angela Shull John Shull Signed (1) The employer does not elect the employers’ liability coverage. Damien Joseph Shull damienshull@gmail.com Self Omaha Douglas Nebraska Angela Shull John Shull Signed
2089 2024-03-12 10:58 Anonymous (not verified) 94.188.205.166 Margarito R Guzman Proprietorship 4512 S 22nd ST Omaha NE 68107 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-12 Margarito R Guzman abrahamguzman030@gmail.com omaha douglas NE jose abraham guzman garcia Drakkar Rapaich Signed (1) The employer does not elect the employers’ liability coverage. Margarito Guzman abrahamguzman030@gmail.com Owner Omaha Douglas Nebraksa jose abraham guzman garcia Drakkar Rapaich Signed
2119 2024-03-27 14:27 Anonymous (not verified) 94.188.205.169 juan garcia Proprietorship 3359 Patrick Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-27 Juan Garcia garcia.stone2022@gmail.com omaha Douglas Nebraska Ashlee Virves Reyna Garcia Signed (1) The employer does not elect the employers’ liability coverage. Juan Garcia garcia.stone2022@gmail.com Self Omaha Douglas Nebraska Ashlee Virves Reyna Garcia Signed
2123 2024-03-28 10:42 Anonymous (not verified) 94.188.207.229 J&J Masonry Proprietorship 2519 Poppleton Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-28 Jose Marroquin drakkarhr7@gmail.com Omaha Douglas Nebraska Drake Rapaich Sunita Rapaich Signed (1) The employer does not elect the employers’ liability coverage. Jose Marroquin drakkarhr7@gmail.com Self Omaha Douglas Nebraska Drake Rapaich Sunita Rapaich Signed
2126 2024-03-29 09:35 Anonymous (not verified) 94.188.207.227 MPO Masonry Proprietorship 5027 s 20th at apt 12 Omaha ne 68107 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-29 Mauricio Ortega pallaresmauricio72@gmail.com Omaha Douglas Nebraska Drake Rapaich Sunita Rapaich Signed (1) The employer does not elect the employers’ liability coverage. Mauricio Ortega pallaresmauricio72@gmail.com Self Omaha Douglas Nebraska Drake Rapaich Sunita Rapaich Signed
2128 2024-03-29 09:52 Anonymous (not verified) 94.188.207.228 Mason Quality and Sons LLC Proprietorship 18921 Willow St Omaha Ne 68136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-29 Joel Castillo drake.centurion@gmail.com Omaha Douglas Nebraska Drake Rapaich Sunita Rapaich Signed (1) The employer does not elect the employers’ liability coverage. Joel Castillo drake.centurion@gmail.com self Omaha Douglas Nebraska Drake Rapaich Sunita Rapaich Signed
122 2020-04-15 18:10 Anonymous (not verified) 136.37.174.39 Merge Midwest Engineering, LLC Limited Liability Company 2668 W. Catalpa Street, Olathe, KS 66061 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-15 Janelle Marie Clayton jclayton@mergemidwest.com Olathe Johnson Kansas David Jahner Patrick McCartney Signed (1) The employer does not elect the employers’ liability coverage. Janelle Marie Clayton jclayton@mergemidwest.com Self Olathe Johnson Kansas David Jahner Patrick McCartney Signed
126 2020-04-21 21:19 Anonymous (not verified) 69.76.135.87 Merge Midwest Engineering, LLC Limited Liability Company 2668 W. Catalpa Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-21 Mark Daniel Stuempel mstuempel@mergemidwest.com Kansas City Wyandotte KANSAS Anna Langer Donna Stuempel Signed (1) The employer does not elect the employers’ liability coverage. Janelle Clayton jclayton@mergemidwest.com LLC Member Olathe Johnson KS Anna Langer Donna Stuempel Signed
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
42 2020-01-24 12:26 Anonymous (not verified) 173.24.181.211 MIKE EDDY Proprietorship PO BOX 437 OKOBOJI, IA 51355 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-22 MIKE EDDY joel@walkerinsuranceia.com OKOBOJI DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. MIKE EDDY JOEL@WALKERINSURANCEIA.COM OWNER OKOBOJI DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
564 2021-07-08 13:33 Anonymous (not verified) 173.31.156.49 SS Docks Limited Liability Company P.O. Box 561 Okoboji IA 51355-0561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-07-08 Jason Andrew Snow snowjas75@gmail.com Lake Park Dickinson IA Amber Egesdal Vickie Walters Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. SS Docks snowjas75@gmail.com Owner Okoboji Dickinson IA Amber Egesdal Vickie Walters Signed
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
869 2022-01-28 15:28 Anonymous (not verified) 63.229.189.35 Jones Painting Proprietorship PO box 523, Okoboji, IA 51355 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-28 JD Jones abigail@rickmilesartisans.com Okoboji Dickinson Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. JD Jones abigail@rickmilesartisans.com Self Okoboji Dickinson Iowa Abigail Miles Alex Miles Signed
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
189 2020-06-16 16:24 Anonymous (not verified) 173.28.58.2 Perry Engel Proprietorship 140 2nd Ave NW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-12 Perry Engel HRSolutionsContracting@gmail.com Oelwein IA United States Danette Hager Tosha Medina Signed (1) The employer does not elect the employers’ liability coverage. Perry Engel HRSolutionsContracting@gmail.com Self Oelwein IA United States Danette Hager Tosha Medina Signed
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
1654 2023-05-19 11:09 Anonymous (not verified) 94.188.205.176 ST SULLIVAN CONSTRUCTION COMPANY Proprietorship 1614 100TH ST., OELWEIN, IOWA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-19 STEVE SULLIVAN sullycon@msn.com Oelwein Fayette Iowa Bobbie J Bergan Shelby Williams Signed (1) The employer does not elect the employers’ liability coverage. STEVE SULLIVAN sullycon@msn.com OWNER OELWEIN FAYETTE IOWA BOBBIE J BERGAN SHELBY WILLIAMS Signed
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
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
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
11 2019-12-17 19:46 Anonymous (not verified) 50.83.188.192 B & B Construction Proprietorship 2463 93rd Avenue, Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-17 Louis I. Maxwell brockbrooke2463@yahoo.com Norwalk IA United States Hope Winegardner Yvonne Ginther Signed (1) The employer does not elect the employers’ liability coverage. Louis Maxwell brockbrooke2463@yahoo.com Owner Norwalk IA United States Hope Winegardner Yvonne Ginther Signed
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
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
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
682 2021-10-19 16:15 Anonymous (not verified) 65.144.174.26 BBR Tile and Professional Installation LLC Proprietorship 903 School Ave Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-19 Bertin Baltazar baltarey2009@gmail.com Norwalk Warren Iowa Enedelia Bonilla Fernando Garcia Signed (1) The employer does not elect the employers’ liability coverage. Bertin Baltazar baltarey2009@gmail.com Owner Norwalk Warren Iowa Enedelia Bonilla Fernando Garcia Signed
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
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
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
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
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
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
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
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
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
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
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
1732 2023-07-10 13:22 Anonymous (not verified) 94.188.207.224 Jovan Guerrero Proprietorship 2887 Jaden Lane Norwalk, Iowa 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-10 Jovan Guerrero deb@piciowa.com Norwalk Warren Iowa Debra Stratton Kelly Denger Signed (1) The employer does not elect the employers’ liability coverage. Jovan Guerrero deb@piciowa.com self Norwalk Warren Iowa Debra Stratton Kelly Denger Signed
1814 2023-08-23 13:57 Anonymous (not verified) 94.188.207.229 Exclusive Solutions LLC dba Jovan Guerrero Limited Liability Company 2887 Jaden Lane Norwalk, Iowa 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-10 Jovan guerrero dba Exclusive Solutions LLC deb@piciowa.com Norwalk Polk Ia Debra Stratton Kelly Denger Signed (1) The employer does not elect the employers’ liability coverage. Jovan Guerrero dba Exclusive SOlutions LLC jovanguerrero29@gmail.com self Norwalk Poik Iowa Debra Stratton Kelly Denger Signed
1953 2023-12-12 15:38 Anonymous (not verified) 94.188.207.226 Ryan Gideon Proprietorship 9320 Elmcrest Dr Norwalk, Ia 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-12 Ryan Gideon rgid8403@gmail.com Norwalk Warren IA Jim Lane Jim Lane Signed (1) The employer does not elect the employers’ liability coverage. Ryan Gideon rgid8403@gmail.com Owner Norwalk Warren IA jim Lane Jim Lane Signed
1959 2023-12-15 13:32 Anonymous (not verified) 94.188.205.169 DeFreeceBuilt LLC Limited Liability Company 216 Rellim Dr Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-15 Dylan DeFreece dylan@defreecebuiltia.com Norwalk Warren Iowa Abigail DeFreece Ricki Schroeder Signed (1) The employer does not elect the employers’ liability coverage. Dylan DeFreece dylan@defreecebuiltia.com N/A Norwalk Warren Iowa Abigail DeFreece Ricki Schroeder Signed
2000 2024-01-26 10:05 Anonymous (not verified) 94.188.205.177 Nick Myers Construction Proprietorship 4736 Candlewick Drive, Norwalk, IA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-26 Nicholas Myers myersnicholasj@gmail.com Norwalk Warren Iowa John Myers Brenda Myers Signed (1) The employer does not elect the employers’ liability coverage. Nicholas Myers nickmyersconstruction@gmail.com Owner Norwalk IA IA John Myers Brenda Myers Signed
2058 2024-02-26 16:32 Anonymous (not verified) 94.188.207.224 performance gutter Proprietorship PO BOX 306, NORWALK IOWA 50211 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-26 RICHARD BAINTER RWBNJ50@AOL.COM NORWALK WARREN IOWA DYLAN LANE JAMES LANE Signed (1) The employer does not elect the employers’ liability coverage. RICHARD BAINTER RWBNJ50@AOL.COM OWNER NORWALK WARREN IOWA DYLAN LANE JAMES LANE Signed
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
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
1010 2022-03-28 09:20 Anonymous (not verified) 173.21.74.26 Self-employed (Stacy Davids) Proprietorship 35 Lynx Lane, North Liberty, IA 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 Stacy Ann Davids stacyanndavids@gmail.com North Libery Johsnons IOWA Darin Gylten Zara Wanlass Signed (1) The employer does not elect the employers’ liability coverage. Stacy Ann Davids stacyanndavids@gmail.com self North Liberty Johnson Iowa Darin Gylten Zara Wanlass Signed
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
1074 2022-04-27 12:16 Anonymous (not verified) 66.129.216.227 Kristyn M Gerst Counseling LLC Limited Liability Company 30 Villager Dr. Apt. 3 North Liberty, IA 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-27 Kristyn May Gerst kmwatson18@gmail.com North Liberty johnson Iowa Forrest John Gerst Heather Lynn Watson Signed (1) The employer does not elect the employers’ liability coverage. Kristyn May Gerst kmwatson18@gmail.com self North Liberty Johnson Iowa Forrest John Gerst Heather Lynn Watson Signed
1307 2022-09-14 13:40 Anonymous (not verified) 216.51.227.123 elite business ckeaning Proprietorship 1350 kennel ct unit c2 north liberty IA 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-14 rogelio morales ortega info@elitebusinesscleaning.com iowa city johnson iowa cesar morales ortega alma rosa perez Signed (1) The employer does not elect the employers’ liability coverage. elite busibess cleaning info@elitebusinesscleaning.com president north liberty johnson iowa karina aguilar jessica lee Signed
1331 2022-10-11 13:17 Anonymous (not verified) 174.216.2.52 Parceros Construction LLC Limited Liability Company 2315 Landon Rd. Apt. 206 North Liberty, IA 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-11 Laura Garavito ldanielagaravitog@gmail.com North Liberty Johnson IA Derek Davis Cory Beesler Signed (1) The employer does not elect the employers’ liability coverage. Laura Garavito ldanielagaravitog@gmail.com Owner North Liberty Johnson IA Derek Davis Cory Beesler Signed
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
1866 2023-10-11 08:17 Anonymous (not verified) 94.188.205.177 Wilson's Window Tinting Limited Liability Company 385 South Stewart Street North Liberty, Iowa 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-07 Wilson Paiva wilsonswindowtinting@gmail.com North Liberty IA United States John W. Helscher Jose Omar Paz Signed (1) The employer does not elect the employers’ liability coverage. Wilson Paiva wilsonswindowtinting@gmail.com Owner North Liberty IA United States John Helscher Jose Omar Paz Signed
1990 2024-01-16 22:22 Anonymous (not verified) 94.188.205.168 DeltaPro Painting & Remodeling Limited Liability Company 1115 Nolan Court North Liberty Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-16 Bayron Amador bayronamador59@gmail.com North Liberty IA Estados Unidos Claudia Garmendia Marlon Amador Signed (1) The employer does not elect the employers’ liability coverage. Bayron Amador bayronamador59@gmail.com Owner/Employer North Liberty IA Estados Unidos Claudia Garmendia Marlon Amador Signed
102 2020-03-25 11:23 Anonymous (not verified) 206.72.14.249 Brandi Wehr Proprietorship 123 E Marion St, Sigourney, IA 52591 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-25 Brandi Jo Wehr brndwehr54@hotmail.com Sigourney Keokuk Iowa Amber Kephart Mary Beth Knipfer Signed (1) The employer does not elect the employers’ liability coverage. Chelsea Voss chelsea@grimmrealestate.com Agent North English Iowa Iowa Amber Kephart Mary Beth Knipfer Signed
1350 2022-10-31 10:42 Anonymous (not verified) 108.160.48.9 gaes trucking Proprietorship 84642 Dun Rd Norfolk, NE 68701 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-31 SHANE GAES scgaes@icloud.com Norfolk NE United States Bill Rich Ben Becker Signed (1) The employer does not elect the employers’ liability coverage. shane gaes scgaes@icloud.com self norfolk pierce county nebraska nebraska Bill Rich Ben Becker Signed
286 2020-10-21 18:32 Anonymous (not verified) 173.218.73.44 Bilyeu Underground LLC Limited Liability Company 1136 W. Irene Ct. Nixa, MO 65714 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Daniel Bilyeu danielbilyeu@gmail.com Nixa Christian Missouri Gary George Bilyeu Chad Anthony Charles Signed (1) The employer does not elect the employers’ liability coverage. Daniel Bilyeu danielbilyeu@gmail.com Owner Nixa Christian Missouri Gary George Bilyeu Chad Anthony Charles Signed
288 2020-10-21 18:36 Anonymous (not verified) 173.218.73.44 Bilyeu Underground LLC Limited Liability Company 1136 W. Irene Ct. Nixa, MO 65714 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Chad Anthony Charles y4ardgn0m3r@gmail.com Nixa Christian Missouri Gary George Bilyeu Daniel Bilyeu Signed (1) The employer does not elect the employers’ liability coverage. Chad Anthony Charles y4ardgn0m3r@gmail.com Owner Nixa Christian Missouri Gary George Bilyeu Daniel Bilyeu Signed
626 2021-08-31 11:39 Anonymous (not verified) 166.181.81.253 Birds landscape maintenance LLC Limited Liability Company 1307 w 4th st south I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-31 Michael Alan bird birdslawn@hotmail.com Newton Jasper Iowa Jeff Dennis carder Dustin James bos Signed (1) The employer does not elect the employers’ liability coverage. Michael Alan bird birdslawn@hotmail.com Same - owner Newton Jasper Iowa Jeff Dennis carder Dustin James bos Signed
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
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
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
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
1210 2022-07-18 08:15 Anonymous (not verified) 173.22.187.234 Cardinal Rule Handyman Services, LLC Limited Liability Company 1304 E 10th St S, Newton, IA 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-18 James Andrew Dunlap cardinarulehandyman@gmail.com Newton Jasper Iowa Jacinda Marie Dunlap James Thornton Dunlap Signed (1) The employer does not elect the employers’ liability coverage. James Andrew Dunlap cardinalrulehandyman@gmail.com I am the authorized agent Newton Jasper Iowa Jacinda Marie Dunlap James Thornton Dunlap Signed
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
1791 2023-08-08 15:22 Anonymous (not verified) 94.188.207.227 dutch meadows lawn care Limited Liability Company 304 W 9TH ST. S. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-08 david nunnikhoven djnunnik@iowatelecom.net newton Iowa United States david nunnikhoven david nunnikhoven Signed (1) The employer does not elect the employers’ liability coverage. david nunnikhoven djnunnik@iowatelecom.net owner newton Iowa United States david nunnikhoven david nunnikhoven Signed
1837 2023-09-11 19:10 Anonymous (not verified) 94.188.207.230 TBA Handyman service Limited Liability Company 619 e 10th st. north newton Iowa 50208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-11 Joey Conkling tba050402@gmail.com newton jasper Iowa Ashton tyler conkling Bianca Storm Conkling Signed (1) The employer does not elect the employers’ liability coverage. TBA Handyman Service tbaconstruction02@gmail.com self newton jasper iowa Ashton tyler Conkling Bianca Storm Conkling Signed
1746 2023-07-14 09:21 Anonymous (not verified) 94.188.205.176 Alex Webb Proprietorship 4019 West Roderweis Road Cabot Ar 72023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-14 Alex Webb frankie.webb@yahoo.com Cabot Pulaski Arkansas Mark Ellis Becky Ellis Signed (1) The employer does not elect the employers’ liability coverage. Ellis Flying Service INC. fly@ellisflying.com President Newport Arkansas United States Alex Webb Becky Ellis Signed
943 2022-03-03 13:49 Anonymous (not verified) 192.95.125.191 B & R Enterprises LLC Limited Liability Company 2850 73rd St, Newhall, IA 52315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-02-17 Ronald Jarrett ashlyn@3riversins.net Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Ronald Jarrett brsirenguys@gmail.com Member of LLC Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed
944 2022-03-03 13:54 Anonymous (not verified) 192.95.125.191 B&R Enterprises LLC Limited Liability Company 2850 73rd St., Newhall, IA 52315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-02-17 Bradley Rick ashlyn@3riversins.net Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Ronald Jarrett brsirenguys@gmail.com LLC Member Newhall Benton Iowa Ashlyn Christianson Angie McFarland Signed
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
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
1864 2023-10-09 09:52 Anonymous (not verified) 94.188.207.223 Admiral Staffing Inc Limited Liability Company 580 8th Ave, 15th Floor, New York NY 10018 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-09 Rezwan Rafeek ray@admiralstaffinginc.com 23 Catalpa Lane Valley Stream NY Ikbal Sherif Salim Balee Signed (1) The employer does not elect the employers’ liability coverage. Shafi Rafeek shafi@admiralstaffinginc.com Office Manager New York NY United States Ikbal Sherif Salin Balee Signed
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
801 2021-12-16 21:35 Anonymous (not verified) 98.21.205.195 Kustom Home Improvements Proprietorship 400 Davidson st new Virginia Iowa 50210 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-16 David Jack Kimmel kustomhomeimprovements.dk@gmail.com New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed (1) The employer does not elect the employers’ liability coverage. David Jack Kimmel kustomhomeimprovements.dk@gmail.com Self New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed
802 2021-12-16 21:44 Anonymous (not verified) 98.21.205.195 Kustom Home Improvements Proprietorship 400 Davidson St New Virginia Iowa 50210 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-16 Jeffrey Allen Webster kustomhomeimprovements.dk@gmail.com New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed (1) The employer does not elect the employers’ liability coverage. David Jack Kimmel kustomhomeimprovements.dk@gmail.com Self New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed
803 2021-12-16 21:47 Anonymous (not verified) 98.21.205.195 Kustom Home Improvements Proprietorship 400 Davidson St New Virginia Iowa 50210 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-16 Ethan Willett kustomhomeimprovements.dk@gmail.com Osceola Clarke Iowa Cindy Sue Gyles Shantell Christine Rice Signed (1) The employer does not elect the employers’ liability coverage. David Jack Kimmel kustomhomeimprovements.dk@gmail.com Self New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed
804 2021-12-16 21:51 Anonymous (not verified) 98.21.205.195 Kustom Home Improvements Proprietorship 400 Davidson st New Virginia Iowa 50210 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-16 Curtis Allen Masterson kustomhomeimprovements.dk@gmail.com New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed (1) The employer does not elect the employers’ liability coverage. David Jack Kimmel kustomhomeimprovements.dk@gmail.com Self New Virginia Warren Iowa Cindy Sue Gyles Shantell Christine Rice Signed
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
1812 2023-08-22 08:00 Anonymous (not verified) 94.188.207.230 mike bethards Proprietorship 3484 vermont st new virginia ia 50210 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-22 mike w bethards mwbethards@yahoo.com new virginia ia United States christine bethards alice lohan Signed (1) The employer does not elect the employers’ liability coverage. mike bethards mwbethards@yahoo.com same new virginia ia United States christine bethards alice lohan Signed
1302 2022-09-11 22:05 Anonymous (not verified) 174.198.65.241 Bruce g Sellner Proprietorship 40998 597th ave new ulm mn 56073 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-11 Bruce g Sellner bgsellner74@gmail.com New ulm Nicollet Minnesota Carol m aura Steve l griebel Signed (1) The employer does not elect the employers’ liability coverage. Bruce g Sellner bgsellner74@gmail.com Owner New ulm Nicollet Mn Carol m aura Steve l griebel Signed
1303 2022-09-11 22:05 Anonymous (not verified) 174.198.65.241 Bruce g Sellner Proprietorship 40998 597th ave new ulm mn 56073 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-11 Bruce g Sellner bgsellner74@gmail.com New ulm Nicollet Minnesota Carol m aura Steve l griebel Signed (1) The employer does not elect the employers’ liability coverage. Bruce g Sellner bgsellner74@gmail.com Owner New ulm Nicollet Mn Carol m aura Steve l griebel Signed
1304 2022-09-11 22:05 Anonymous (not verified) 174.198.65.241 Bruce g Sellner Proprietorship 40998 597th ave new ulm mn 56073 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-11 Bruce g Sellner bgsellner74@gmail.com New ulm Nicollet Minnesota Carol m aura Steve l griebel Signed (1) The employer does not elect the employers’ liability coverage. Bruce g Sellner bgsellner74@gmail.com Owner New ulm Nicollet Mn Carol m aura Steve l griebel Signed
608 2021-08-17 21:35 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, IA. 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-17 James D VanderBeek jvanderbeek@plbci.com New Sharon Mahaska IA Barbara M VanderBeek Zackery James VanderBeek Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Spouse New Sharon Mahaska IA James D VanderBeek Zackery J VanderBeek Signed
609 2021-08-17 21:42 Anonymous (not verified) 50.82.65.174 33z Racing, LLC Limited Liability Company 307 N Park Ave, New Sharon, IA. 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-17 Zackery James VanderBeek zackvanderbeek@gmail.com New Sharon Mahaska IA Barbara M VanderBeek James. VanderBeek Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Mother New Sharon Mahaska IA James D VanderBeek Barbara M VanderBeek Signed
612 2021-08-19 21:50 Anonymous (not verified) 50.82.65.174 33z Racing,, LLC Limited Liability Company 307 N Park Ave, New Sharon, Iowa 50207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-20 James Dean VanderBeek jvanderbeek@plbco.com New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed (1) The employer does not elect the employers’ liability coverage. Barbara M VanderBeek bvanderbeek33z@gmail.com Spouse New Sharon Mahaska Iowa Margaret Ratcliff Billy Blake Signed
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
2208 2024-05-07 12:44 Anonymous (not verified) 94.188.205.169 Tom Franklin Proprietorship 2353 Salem Road, New London, IA 52645 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Thomas Eric Franklin 68carpetman@gmail.com New London Henry Iowa Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Thomas Eric Franklin 68carpetman@gmail.com owner New London Henry Iowa Cheryl Ross Larry Rheinschmidt Signed
24 2020-01-03 12:41 Anonymous (not verified) 63.152.13.239 Eden Plumbing LLC TJ Eden Limited Liability Company 502 Packwaukee Street New Hartford, IA 50660 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-03 TJ Eden edentj@aol.com New Hartford IA United States Ann Robinson Nate Schmidt Signed (1) The employer does not elect the employers’ liability coverage. PDCM Insurance- Nate Schmidt NSCHMIDT@PDCM.COM Member New Hartford Butler Iowa Ann Robinson Nate Schmidt Signed
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
1338 2022-10-17 15:53 Anonymous (not verified) 74.84.121.206 Mark Mitchell Proprietorship P O Box 38 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-15 Mark Mitchell darrele@ciains.biz New Albion Allamakee Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Mark Mitchell darrele@ciains.biz Self New Albion Allamakee Iowa Chris Fye Darrel Elsbernd Signed
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
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
2202 2024-05-06 11:36 Anonymous (not verified) 94.188.207.224 Neil Wedeking Proprietorship 408 Maple St, Nemaha, IA 50567 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-06 Neil Douglas Wedeking nandjwedeking@frontiernet.net Nemaha Sac Iowa Joseph McCollum Heather Husman Signed (1) The employer does not elect the employers’ liability coverage. Neil Wedeking nandjwedeking@frontiernet.net Self Nemaha Sac Iowa Joseph Paul McCollum Heather Lee Husman Signed
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
2001 2024-01-26 10:41 Anonymous (not verified) 94.188.207.225 4 Sons Splicing & Activation Proprietorship 13510 W Brazos Bend Dr, Needville, TX 77461-9525 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-26 John Kevin Steil foursons1990@steil.org Needville Ft. Bend Texas Dennis Reeves Oliver Stephanie Ranae Oliver Signed (1) The employer does not elect the employers’ liability coverage. Helen Frances Steil foursons1990@steil.org Spouse Needville Ft. Bend Texas Dennis Reeves Oliver Stephanie Ranae Oliver Signed
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
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
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
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
1418 2023-01-11 10:44 Anonymous (not verified) 173.23.144.232 precision edge llc Limited Liability Company 101 belmont st milo iowa 50116 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-10 erik reha precisionedgecompanies@gmail.com milo warren iowa bruce wilson jordan rhode Signed (1) The employer does not elect the employers’ liability coverage. n/a precisionedgecompanies@gmail.com n/a n/a n/a n/a bruce wilson jordan rhode Signed
257 2020-09-14 16:15 Anonymous (not verified) 66.129.217.166 Lisseth Carolina Salas Melendez Proprietorship 3107 M & W Crl Muscatine, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-01 Lisseth Carolina Salas Melendez chonrosales88@gmail.com Muscatine Louisa IA Rafael Crespo Anthony Johnson Signed (1) The employer does not elect the employers’ liability coverage. Lisseth Carolina Salas Melendez chonrosales88@gmail.com Same Muscatine Louisa IA Rafael Crespo Anthony Johnson Signed
346 2020-12-31 10:39 Anonymous (not verified) 66.129.217.166 GIL Construction, LLC Limited Liability Company 3107 M & W Crl, Muscatine, IA 52761 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-20 Lisseth Melendez Gil chonrosales88@gmail.com Muscatine Iowa United States Donis Medina Anthony Johnson Signed (1) The employer does not elect the employers’ liability coverage. Lisseth Melendez Gil chonrosales88@gmail.com Owner Muscatine Iowa United States Donis Medina Anthony Johnson Signed
1639 2023-05-11 07:39 Anonymous (not verified) 94.188.205.175 JYC Drywall LLC Proprietorship 1034 Grand Ave, Muscatine, IA 52761 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-11 Anastacio Zamarripa 1zama0081@gmail.com Muscatine Louisa Iowa Arcel Servin Chris Hay Signed (1) The employer does not elect the employers’ liability coverage. Anastacio Zamarripa 1zama0081@gmail.com Self Muscatine Louisa Iowa Arcel Servin Chris Hay Signed
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
1995 2024-01-23 15:08 Anonymous (not verified) 94.188.205.167 Spencer Abbott Proprietorship 1358 170th Ave, Murray Iowa 50174 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-23 Spencer Abbott sabbott1800@gmail.com Murray Clarke Iowa Juanita Yutzy Elaine Lee Signed (1) The employer does not elect the employers’ liability coverage. Spencer Abbott sabbott1800@gmail.com sole proprietor Murray Clarke Iowa Juanita Yutzy Elaine Lee Signed
2185 2024-04-26 16:46 Anonymous (not verified) 94.188.205.166 Jerilyn Horn Kitchen and Bath Design Co. Proprietorship 413 Jefferson St., Burlington, IA 52601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-26 Jerilyn Michelle Horn designsbyjerilyn@gmail.com Mt. Pleasant Henry Iowa Cheryl Ross Larry Rheinschmidt Signed (1) The employer does not elect the employers’ liability coverage. Jerilyn Michelle Horn designsbyjerilyn@gmail.com owner Mt. Pleasant Henry Iowa Cheryl Ross Larry Rheinschmidt Signed
637 2021-09-10 15:15 Anonymous (not verified) 204.155.61.217 Duwa Waterproofing LLC Limited Liability Company 1548 150th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-10 Stacy Duwa duwawaterproofing@gmail.com Mt Pleasant Henry Iowa Jeffrey Spenner Shawn Powell Signed (1) The employer does not elect the employers’ liability coverage. Stacy Duwa duwawaterproofing@gmail.com owner Mt Pleasant Henry Iowa Jeffrey Spenner Shawn Powell Signed
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
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
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
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
208 2020-07-16 20:24 Anonymous (not verified) 216.127.193.93 Sequoia Integrative Medical Services Limited Liability Company W2560 Birschbach Drive, Mount Calvary, WI, 53057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-16 Chad Weston Gardner chadwestongardner@yahoo.com Mount Calvary Fond du Lac Wisconsin Emily Lucht Ron Carpenter Signed (1) The employer does not elect the employers’ liability coverage. Chad Weston Gardner chadwestongardner@yahoo.com Self Mount Calvary Fond du Lac Wisconsin Emily Lucht Ron Carpenter Signed
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
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
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
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
1755 2023-07-19 22:43 Anonymous (not verified) 94.188.207.230 Ellison building and repair Limited Liability Company 2722 645th ave moravia iowa 52571 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-19 Keeton Ellison sammyllsn@yahoo.com Moravia Appanoose Iowa Cory Ellison Sammy Ellison Signed (1) The employer does not elect the employers’ liability coverage. Sammy Ellison sammyllsn@yahoo.com Mom Moravia Monroe Iowa Cory Ellison Sammy Ellison Signed
1822 2023-08-29 11:52 Anonymous (not verified) 94.188.207.224 Ellison building and repair Limited Liability Company 2722 645th ave moravia iowa 52571 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-18 Keeton Ellison keeton2005@gmail.com Moravia Appanoose Iowa Cory Ellison Sammy Ellison Signed (1) The employer does not elect the employers’ liability coverage. Sammy Ellison sammyllsn@yahoo.com Mom Moravia Monroe Iowa Cory Ellison Sammy Ellison Signed
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
1040 2022-04-12 09:36 Anonymous (not verified) 173.31.148.43 PAPA'S SMOKIN MEAT Proprietorship 1940 147TH ST SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-12 KEITH MORISTON PAPASSMOKINMEAT@GMAIL.COM MONTGOMERY DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. KEITH MORISTON PAPASSMOKINMEAT@GMAIL.COM SELF MONTGOMERY DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1041 2022-04-12 09:39 Anonymous (not verified) 173.31.148.43 PAPA'S SMOKIN MEAT Proprietorship 1940 147TH ST SPIRIT LAKE, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-12 ROXANNE MORISTON MORISTON2@YAHOO.COM MONTGOMERY DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ROXANNE MORISTON MORISTON2@YAHOO.COM SELF MONTGOMERY DICKINSON IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
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
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
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
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
1117 2022-05-18 10:33 Anonymous (not verified) 74.84.106.106 Tina Owens Proprietorship 4162 Hwy F62 West Monroe, Iowa 50170 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-18 Tina M Owens towens974447@yahoo.com Monroe Jasper Iowa Ashley Owens Steve Wimer Signed (1) The employer does not elect the employers’ liability coverage. Tina Owens towens974447@yahoo.com self Monroe Jasper Iowa Ashley Ann Owens Steve Edwin Wimer Signed
1460 2023-02-16 12:36 Anonymous (not verified) 94.188.205.174 Certified Septic Service Proprietorship 2121 Rodeo ave monroe iowa 50170 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-16 Justin Rozendaal jusroz12@gmail.com Monroe Jasper Iowa Justin Rozendaal Miranda Rozendaal Signed (1) The employer does not elect the employers’ liability coverage. Justin Rozendaal certifiedseptic@gmail.com Self Monroe Jasper Iowa Justin Rozendaal Miranda Rozendaal Signed
573 2021-07-14 09:12 Anonymous (not verified) 166.181.83.201 Dustin Demoss Proprietorship 407 mechanic st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-13 Dustin Michael DeMoss dustindemoss14@gmail.com Monmouth Iowa United States Jake Jake Signed (1) The employer does not elect the employers’ liability coverage. Dustin Michael DeMoss dustindemoss14@gmail.com Idk Monmouth Iowa United States Jake Jake Signed
232 2020-08-16 11:28 Anonymous (not verified) 173.27.57.39 Landeros & Sons Construction, Inc Limited Liability Partnership 1636 19th Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-16 Fernando Landeros fland1983@gmail.com Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed (1) The employer does not elect the employers’ liability coverage. Emanuel Landeros fland1983@gmail.com Brother Moline Rock Island Illinois Adrian Landeros Emanuel Landeros Signed
260 2020-09-17 10:52 Anonymous (not verified) 50.80.218.18 Decanus Property Management Proprietorship 102 E 2nd St, Davenport IA 52801 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-17 Shonna Suzanne Dean decanus@yahoo.com Moline Rock Island Illinois Justin E Proctor Elizabeth A Oney Signed (1) The employer does not elect the employers’ liability coverage. Shonna S Dean decanus@yahoo.com Self Moline Rock Island Illinois Justin E Proctor Elizabeth A Oney Signed
473 2021-04-13 11:26 Anonymous (not verified) 65.103.82.36 Quality Renovation Proprietorship 1406 25th st Moline IL 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-06-21 Clarence Marvin Skipton marvinthemartien77@gmail.com Buffalo Scott IA Jennifer Skipton Rose mary Skipton Signed (1) The employer does not elect the employers’ liability coverage. Clarence Marvin Skipton marvinthemartien77@gmail.com Owner Moline Rock Island IL Jennifer skipton rose Skipton Signed
579 2021-07-20 12:37 Anonymous (not verified) 166.205.124.133 M&M HOME IMPROVEMENT Limited Liability Company 5406 28th Ave. Moline , IL 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-07-20 Jarred Alexander bookkyddjay@gmail.com Moline USA IL Jacob Nagel Jacob Nagel Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jarred Alexander bookkyddjay@gmail.com Same Moline USA IL Jacob Nagel Jacob Nagel Signed
646 2021-09-20 08:54 Anonymous (not verified) 173.24.107.209 QCA Professional Contractors Limited Liability Company 3314 67th Ave, Moline, IL. 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-20 Allan Celada allancelada@qcaprocontractors.com Moline Rock Island IL Alexander Celada Drexel Miller Signed (1) The employer does not elect the employers’ liability coverage. Allan Celada allancelada@qcaprocontractors.com self Moline Rock Island IL Alexander Celada Drexel Miller Signed
751 2021-11-16 15:51 Anonymous (not verified) 166.181.83.87 Dylan Wilson SMS & More Proprietorship 7500 25th Milan IL 61264 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-16 Dylan Wilson doe33843@gmail.com Milan Rock Island IL Jamie Short Brett Dawson Signed (1) The employer does not elect the employers’ liability coverage. Jennifer Groech wilsoncrazy@gmail.com Grandmother Moline Rock Island IL Jamie Short Brett Dawson Signed
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
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
1848 2023-09-19 10:20 Anonymous (not verified) 94.188.207.226 Josh Woodworth Proprietorship 16405 u.s. 67 milan il 61264 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-19 Josh woodworth joshwoodworth84@live.com milan Rock island Illinois Cody dunbar Jordan nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Cody dunbar cdunbar@leaffilter.com Install manager moline Rock island illinois Cody dunbar Jordan nisiewic Signed
2199 2024-05-03 13:27 Anonymous (not verified) 94.188.207.228 Polar Delights LLC DBA Twists Ice Cream Limited Liability Company 110 S 9th Ave Eldridge IA 52748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-03 Anna Kokity amkokity@gmail.com Moline Rock Island IL Ashley Schwien Kasey Lange Signed (1) The employer does not elect the employers’ liability coverage. Anna Kokity amkokity@gmail.com self Moline Rock Island IL Ashley Schwien Kasey Lange Signed
2039 2024-02-08 09:25 Anonymous (not verified) 94.188.207.229 Home Re Construction, LLC Limited Liability Company 5285 NE Mitchell Drive, Mitchellville, IA 50169 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-08 Francisco Miguel Palomares Velasco homereconstruction@hotmail.com Mitchellville Polk Iowa Fabiola Palomares Recendiz Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Francisco Miguel Palomares Velasco homereconstruction@hotmail.com Self Mithcellville Polk Iowa Fabiola Palomares Recendiz Nathan Miller Signed
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
61 2020-02-13 08:44 Anonymous (not verified) 71.28.216.94 Cyclone Captioning, Inc Proprietorship 8866 W 122nd Street N, Mingo, IA 50168 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-13 Holli L. Schneider Hlschneid87@gmail.com Mingo Jasper IA Dan Herrin Minda Dearden Signed (1) The employer does not elect the employers’ liability coverage. Holli Schneider hlschneid87@gmail.com President of Proprietorship Mingo Jasper IA Dan Herrin Minda Dearden Signed
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
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
1422 2023-01-14 10:26 Anonymous (not verified) 71.39.227.238 Udderly Great Downtown Scoops LLC Limited Liability Company 530 Walnut St, PO Box 251, Waukee, IA 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-09 Stephani S Jimmerson stephjimmerson67@gmail.com Minburn Dallas Iowa Abbey Luellen Laura Richardson Signed (1) The employer does not elect the employers’ liability coverage. Don Richardson DonR@phillipsassociatesins.net Agent Minburn Dallas Iowa Abbey Luellen Laura Richardson Signed
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
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
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
179 2020-06-09 11:22 Anonymous (not verified) 173.31.147.225 SAUL GUERARA MEZA Proprietorship 26 WESTVIEW DRIVE APT 5 MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-21 SAUL GUERARA MEZA ESMEJ2513@GMAIL.COM MILFORD DICKINSON IOWA ESMIRALDO JIMENEZ TAMI KLEIN Signed (1) The employer does not elect the employers’ liability coverage. SAUL GUERARA MEZA ESMEJ2513@GMAIL.COM SELF MILFORD DICKINSON IOWA ESMIRALDO JIMENEZ TAMI KLEIN Signed
327 2020-11-25 10:38 Anonymous (not verified) 173.31.147.225 CASEY KYLE Proprietorship 1505 9TH ST MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-01 CASEY KYLE JOEL@WALKERINSURANCEIA.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. CASEY KYLE JOEL@WALKERINSURANCEIA.COM SELF MILFORD DISCKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
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
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
514 2021-05-11 13:16 Anonymous (not verified) 173.31.147.225 RUTHVEN ROCKS LLC Limited Liability Company 1205 ROLLING ST RUTHVEN IOWA 51358 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-11 MATT CACEK MATT@RUTHVENROCKS.COM MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. MATT CACEK joel@walkerinsuranceia.com MEMBER MILFORD PALO ALTO IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
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
670 2021-10-13 12:30 Anonymous (not verified) 173.19.179.111 MULLER TRANSPORT LLC Limited Liability Company 2083 260TH ST MILFORD, IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-13 PAUL MULLER MULLERTANSPORTLLC@GMAIL.COM MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. PAUL MULLER JOEL@WALKERINSURANCEIA.COM SELF MILFORD DICKINSON IOWA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
783 2021-12-08 10:25 Anonymous (not verified) 173.31.148.43 Nick Larsen Proprietorship 1305 7th St. Milford, IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-08 Nick Larsen larsennick77@gmail.com Milford Dickinson IA JOSEPH THOMAS LORING Kristine Ann Walker Signed (1) The employer does not elect the employers’ liability coverage. Nick Larsen joel@walkerinsuranceia.com Self Milford Dickinson IA JOSEPH THOMAS LORING Kristine Ann Walker Signed
786 2021-12-09 15:37 Anonymous (not verified) 216.51.251.31 3F Express, LLC Limited Liability Company 920 32nd Ave West Po Box 1117 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. 2021-12-09 Tess Jackson accounting@3fexpressllc.com Milford Dickinson Iowa Amanda Wolff Mandy Kabrick Signed (1) The employer does not elect the employers’ liability coverage. Tess Jackson accounting@3fexpressllc.com Owner Milford Dickinson IA Amanda Wolff Mandy Kabrick 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
1314 2022-09-19 16:43 Anonymous (not verified) 96.31.1.206 CHARVEL TREJO Proprietorship 1113 L AVE, MILFORD, IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-19 CHARVEL TREJO LEVRACH@YAHOO.COM MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. CHARVEL TREJO LEVRACH@YAHOO.COM SELF MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
1756 2023-07-20 11:19 Anonymous (not verified) 94.188.205.169 LEVI GONZALEZ Proprietorship 2212 OKOBOJI AVE MILFORD, IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-13 LEVI GONZALEZ joel@walkerinsuranceia.com MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI KLEIN Signed (1) The employer does not elect the employers’ liability coverage. LEVI GONZALEZ JOEL@WALKERINSURANCEIA.COM SELF MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI KLEIN Signed
1836 2023-09-11 09:26 Anonymous (not verified) 94.188.205.174 Felisha Schmitz Proprietorship 505 Q AVENUE MILFORD IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-08 FELISHA SCHMITZ PETERNFISH@GMAIL.COM MILFORD DICKINSON IA JENNIFER YOUNGWIRTH TAMI KLEIN Signed (1) The employer does not elect the employers’ liability coverage. FELISHA SCMITZ PETERNFISH@GMAIL.COM SELF MILFORD DICKINSON IA JENNIFER YOUNGWIRTH TAMI KLEIN Signed
1892 2023-11-02 12:24 Anonymous (not verified) 94.188.205.169 TREJO'S CONSTRUCTION LLC Limited Liability Company 1113 L AVE, MILFORD, IA 51351 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-02 CHARVEL TREJO levrach@yahoo.com MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed (1) The employer does not elect the employers’ liability coverage. CHARVEL TREJO levrach@yahoo.com SELF MILFORD DICKINSON IA JOSEPH THOMAS LORING TAMI SUE KLEIN Signed
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
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
496 2021-04-23 12:48 Anonymous (not verified) 173.29.190.18 A+ Roofing and Siding Co Proprietorship 1636 15th St Pl, Moline, IL 61265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-22 SHAWN HICKS APLUSROOFINGQCA@YAHOO.COM Milan IL United States deena hicks Mike Chandler Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. SHAWN HICKS APLUSROOFINGQCA@YAHOO.COM SELF/OWNER Milan IL United States deena hicks Mike Chandler Signed
598 2021-08-06 19:04 Anonymous (not verified) 107.77.208.84 Paul Adams Proprietorship 914 Bayfield drive Denton TX 76209 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-06 Paul T Adams ptadams61@yahoo.com Denton Denton Tx Jeanie Moses Richard Moses Signed (1) The employer does not elect the employers’ liability coverage. Paul T Adams ptadams61@yahoo.com Friends Milan Rock Island Illinois Jeanie Moses Richard Moses Signed
2095 2024-03-14 11:39 Anonymous (not verified) 205.221.255.62 Trimble Lawncare And Landscaping Proprietorship 215 Boundary Ave Middletown IA 52638 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-14 Kevin Blake Trimble rknhtrimble@yahoo.com Middletown Des Moines Iowa Katelyn Orth Shayla Taeger Signed (1) The employer does not elect the employers’ liability coverage. Kevin Blake Trimble rknhtrimble@yahoo.com owner Middletown Des Moines Iowa Katelyn Orth Shayla Taeger Signed
597 2021-08-05 13:38 Anonymous (not verified) 204.155.61.217 Haag Consulting LLC Limited Liability Company 8602 E Kael Circle, Mesa, AZ 85207 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-05 Justin Haag haag.justin1@gmail.com Mesa unknown AZ DocuSign Ashley Kraft Signed (1) The employer does not elect the employers’ liability coverage. Justin Haag haag.justin1@gmail.com Owner Mesa unknown AZ DocuSign Ashley Kraft Signed
895 2022-02-04 11:57 Anonymous (not verified) 216.189.133.155 A1A Sandblasting (Iowa) Proprietorship 334 main street S.W. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-04 michael d marjama mike.orie@yahoo.com menahga MN United States Josh Louviere Kevin Tomperi Signed (1) The employer does not elect the employers’ liability coverage. michael d marjama mike.orie@yahoo.com Owner menahga MN United States Josh Louviere Kevin Tomperi Signed
282 2020-10-21 07:00 Anonymous (not verified) 98.16.114.26 Fine Cut Lawn Service, LLC Limited Liability Partnership 110 E Street, SW. P.O. Box 835 Melcher, IA. 50163 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-19 Eric E Benz eric@finecutwaterscapes.com Melcher Marion IA Angelia Warner Allen Smith Signed (1) The employer does not elect the employers’ liability coverage. Eric Eugene Benz eric@finecutlawn.com same person Melcher Marion IA Angela Warner Allen Smith Signed
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
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
1539 2023-03-28 16:50 Anonymous (not verified) 94.188.207.230 Sulzner Construction LLC Limited Liability Company 210 N CHERRY ST, PO BOX 264 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-28 Aksel C Sulzner akselsmoke@gmail.com Mechanicsville IA United States self self Signed (1) The employer does not elect the employers’ liability coverage. Aksel C Sulzner akselsmoke@gmail.com Self Mechanicsville IA United States self self Signed
1543 2023-03-29 15:37 Anonymous (not verified) 94.188.207.225 Sulzner Construction LLC Limited Liability Company 210 N CHERRY ST, PO BOX 264 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-29 Aksel C Sulzner akselsmoke@gmail.com Mechanicsville IA United States Toni Pollard Phil Rouse Signed (1) The employer does not elect the employers’ liability coverage. Aksel C Sulzner akselsmoke@gmail.com Self Mechanicsville IA United States Toni Pollard Phil Rouse Signed
1764 2023-07-27 09:56 Anonymous (not verified) 94.188.207.224 Tracy Spray Proprietorship 479 old lincoln hwy Mechanicsville Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-27 Tracy spray tspray9@hotmail.com Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed (1) The employer does not elect the employers’ liability coverage. Tracy Spray tspray9@hotmail.com Owner Mechanicsville Cedar Iowa Dillon Williams Leighton Raplinger Signed
2013 2024-01-31 15:14 Anonymous (not verified) 94.188.205.167 Aspen Ridge LLC Limited Liability Company 1404 G Ave Marengo, IA 52301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-10 Jeffrey McKusker jeff@mckuskerelectric.com Marengo Iowa Iowa Karly Kovar Jacob McKusker Signed (1) The employer does not elect the employers’ liability coverage. Lori McKusker jeff@mckuskerelectric.com Spouse Mead Weld Colorado Karly Kovar Jacob McKusker Signed
2014 2024-01-31 15:17 Anonymous (not verified) 94.188.205.174 Aspen Ridge LLC Limited Liability Company 1404 G Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-10 Lori McKusker lori@mckuskerelectric.com Mead Weld Colorado Karly Kovar Jacob McKusker Signed (1) The employer does not elect the employers’ liability coverage. Lori McKusker jeff@mckuskerelectric.com Self Mead Weld Colorado Karly Kovar Jacob McKusker Signed
1345 2022-10-25 15:25 Anonymous (not verified) 166.181.82.169 Estling Junk and Garbage Removal Limited Liability Company 660 West Main Street Apt.5 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-10-25 Jacob Steven Estling JacobEstling1@gmail.com Maynard Fayette Iowa Jacob Estling Jacob Estling Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jacob Steven Estling jacobestling1@gmail.com Owner Maynard Fayette Iowa Jacob Estling Jacob Estling Signed
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
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
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
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
530 2021-05-25 08:30 Anonymous (not verified) 159.242.43.24 FoxTrot Foods, LLC Limited Liability Company 13-15 S Federal Ave, Mason City IA 50401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-25 Melissa Fabian melissafabian@yahoo.com Mason City Cerro Gordo Iowa Jenny McIntyre Dan Wunschel Signed (1) The employer does not elect the employers’ liability coverage. Melissa Fabian melissafabian@yahoo.com Owner-Member Mason City Cerro Gordo Iowa Jenny McIntyre Dan Wunschel Signed
531 2021-05-26 13:02 Anonymous (not verified) 75.162.156.185 Xander Wessels Limited Liability Company 719 10TH ST NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-26 Alexander Wessels kprepair@outlook.com MASON CITY IA IA Dusty Howe Sadie Lonning Signed (1) The employer does not elect the employers’ liability coverage. Dusty Howe dusty.mcelectric@gmail.com Sub Contractor Mason City Cerro Gordo Iowa Dusty Howe Sadie Lonning Signed
533 2021-06-03 20:37 Anonymous (not verified) 75.162.171.128 KP Repair LLC Limited Liability Company 719 10th St. NE Mason City, Iowa. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-03 Alexander Wessels kprepair@outlook.com MASON CITY Cerro Gordo IA Sadie Lonning Dusty Howe Signed (1) The employer does not elect the employers’ liability coverage. Alexander Wessels kprepair@outlook.com Owner MASON CITY Cerro Gordo IA Sadie Lonning Dusty Howe Signed
1903 2023-11-13 09:08 Anonymous (not verified) 94.188.207.228 Christopher Stone Proprietorship 2427 S Taft Ave Apt #8 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-10 Christopher Stone darrele@ciains.biz Iowa Cerro Gordo IA Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Christopher Stone darrele@ciains.biz self Mason City Cerro Gordo Iowa Chris Fye Darrel Elsbernd Signed
1907 2023-11-15 09:45 Anonymous (not verified) 94.188.205.168 Dan Taylor Proprietorship 1422 State ST. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-15 Daniel Taylor mailrunner1958@gmail.com Mason City Cerro Gordo IA Bob Smith Dave Clark Signed (1) The employer does not elect the employers’ liability coverage. Daniel Taylor mailrunner1958@gmail.com employee Mason City Cerro Gordo IA Bob Smith Dave Clark Signed
1787 2023-08-07 13:15 Anonymous (not verified) 94.188.205.177 Dryseal Roofing and Construction Proprietorship 390 olive st. Martensdale, Iowa 50160 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-07 Travis w. Tibbits travistibbits@yahoo.com Martensdake Warren Iowa Dawn Marie tibbits Chad David walker Signed (1) The employer does not elect the employers’ liability coverage. Travis Wayne Tibbits travistibbits@yahoo.com Self Martensdale Warren Iowa Dawn Marie Tibbits Chad David walker 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
827 2022-01-10 16:36 Anonymous (not verified) 167.142.141.89 Hill Lawn Care Proprietorship 2307 Campbell Dr Marshalltown Iowa 50158 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-10 Raymond Hill rayhill_19@hotmail.com Marshalltown Marshall Iowa Kaitlyn Schuring Matt Gannaway Signed (1) The employer does not elect the employers’ liability coverage. Raymond Hill rayhill_19@hotmail.com Self Marshalltown Marshall Iowa Kaitlyn Schuring Matt Gannaway Signed
978 2022-03-15 12:42 Anonymous (not verified) 173.24.17.213 Jose Antonio Hernández Tobar Limited Liability Company 219 Huisman Cir I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Jose Antonio Hernandez Tobar josehernanr5@icloud.com Marshalltown Marshall Iowa Cindy Garcia Hernandez Jaquelin Garcia Barajas Signed (1) The employer does not elect the employers’ liability coverage. Jose Antonio Hernandez Tobar josehernanr5@icloud.com Self Marshalltown Marshall Iowa Cindy Garcia Hernandez Jaquelin Garcia Barajas Signed
1066 2022-04-22 11:17 Anonymous (not verified) 50.83.107.151 Delos Steward Proprietorship 1310 w Main Street Marshalltown iowa 50158 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-22 Delos Lyle Steward LDSPlastering2020@gmail.com Marshalltown Marshall Iowa Chris Hart Jody Steward Signed (1) The employer does not elect the employers’ liability coverage. LDS Plastering ldsplastering2020@gmail.com Owner Marshalltown Marshall Iowa Chris Hart Jody Steward Signed
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
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
1552 2023-04-03 13:58 Anonymous (not verified) 94.188.205.168 F&I Drywall Llc Limited Liability Company 509 Arlington Dr. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-03 Fernando Garcia Fgarcia1989.fg@gmail.com Marshalltown Marshall Iowa Gabriela Garcia Araceli Tafolla Signed (1) The employer does not elect the employers’ liability coverage. Fernando Garcia Fgarcia1989.fg@gmail.com Self Marshalltown Marshall Iowa Gabriela Garcia Araceli Tafolla Signed
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
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
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
331 2020-12-03 10:19 Anonymous (not verified) 174.213.165.124 TTC Cleaning Services Limited Liability Company 2155-230th 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. 2020-12-03 Zachary Stephen Bolar zbolar80@gmail.com Marshalltown Marshall IA Brian Mason Casey Jesina Signed (1) The employer does not elect the employers’ liability coverage. Zachary Stephen Bolar zbolar80@gmail.com Self Marshall Marshall IA Brian Mason Casey Jesina 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
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
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
878 2022-01-31 12:37 Anonymous (not verified) 63.152.234.243 It's a Breeze Cleaning Service Proprietorship 760 W 8th Ave, Marion, IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-31 Breonna Kay Nelson breanderson82@yahoo.com Marion Linn Iowa Anna Walbridge Tyler Nelson Signed (1) The employer does not elect the employers’ liability coverage. Breonna Kay Nelson breanderson82@yahoo.com Self Marion Linn Iowa Anna Walbridge Tyler Nelson Signed
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
966 2022-03-11 10:04 Anonymous (not verified) 173.19.189.168 Steger Siding & Construction Limited Liability Company 1020 25th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-11 Jared Steger jared.steger@gmail.com Marion IA United States Jared Steger Jared Steger Signed (1) The employer does not elect the employers’ liability coverage. Jared Steger jared.steger@gmail.com self Marion IA United States Jared Steger Jared Steger Signed
1152 2022-06-13 13:05 Anonymous (not verified) 70.96.153.153 Tyler Ankney Proprietorship 1250 A 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. 2022-06-13 Tyler Ankney tyler.a@optionsexteriors.com Marion Linn County Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Tyler Ankney tyler.a@optionsexteriors.com Owner Marion Linn County Iowa Charlotte Rasmussen Austin Miller Signed
1222 2022-07-21 16:01 Anonymous (not verified) 66.129.208.246 James J Stallman Proprietorship 190 BLUFF DR, Fairfax, IA 52228 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-21 James J Stallman stallmanjim@aol.com FAIRFAX IA United States James J Stallman James J Stallman Signed (1) The employer does not elect the employers’ liability coverage. Lundahl, Hatt, Austad Tax Services Inc NN@LHAtax.com President Marion Linn IA James J Stallman James J Stallman Signed
1238 2022-08-02 10:24 Anonymous (not verified) 70.96.153.153 Matthew Smith Proprietorship 2070 Golfview Ct, Marion, IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-02 Matthew Smith matt.s@optionsexteriors.com Marion Linn Iowa Charlotte Rasmussen Aus Signed (1) The employer does not elect the employers’ liability coverage. Matthew Smith matt.s@optionsexteriors.com Self/Owner Marion Linn Iowa Charlotte Rasmussen Austin Miller Signed
1288 2022-08-30 16:23 Anonymous (not verified) 50.83.35.94 Black Rock Flooring LLC Limited Liability Company 189 9th st. Marion,Ia 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-30 Keith Douglas Luye Sr. Blackrockflooriing@gmail.com Marion Linn Iowa Cari Beth Lamb Daniel Ray Lamb Signed (1) The employer does not elect the employers’ liability coverage. Keith Douglas Luye Sr. Blackrockflooring@gmail.com self / my own authorized agent Marion Linn Iowa Cari Beth Lamb Daniel Ray Lamb Signed
1300 2022-09-07 16:38 Anonymous (not verified) 174.198.70.216 Phillip Phelps Proprietorship 2900 4th St Marion, IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Phillip Phelps phillipphelps8732@yahoo.com Marion Linn Iowa Kaitlin Davidson Kevin Phelps Signed (1) The employer does not elect the employers’ liability coverage. Phillip Phelps phillipphelps8732@yahoo.com Self Marion Linn Iowa Kaitlin Davidson Kevin Phelps Signed
1358 2022-11-03 23:03 Anonymous (not verified) 172.86.32.251 LeafFilter North LLC Limited Liability Company 1020 James Drive Suite A | Hartland, WI 53209 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-03 Aaron Bensinger guttershereandnow@outlook.com Marion Linn Iowa Silvena Cammareri Aaron Bensinger Signed (1) The employer does not elect the employers’ liability coverage. Aaron Bensinger guttershereandnow@outlook.com Self Marion Linn Iowa Aaron Bensinger Silvena Cammareri Signed
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
1795 2023-08-11 08:02 Anonymous (not verified) 94.188.205.176 Overall Cleaning Proprietorship 507 Enterprise Ct #6 Independence IA 50644 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-11 Michelle L. Vonsprecken michelle.vonsprecken@gmail.com Independence Buchanan Iowa Jacob Von Sprecken Cody Caraway Signed (1) The employer does not elect the employers’ liability coverage. Justin C Hayes overallcleaning21@gmail.com Business Partner Marion Linn IA Cody Caraway Jacob Von Sprecken Signed
2206 2024-05-07 09:10 Anonymous (not verified) 94.188.205.166 Stephanie Farmer Proprietorship 600 6th Ave, Marion, IA 52302 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-07 Stephanie Farmer farmer.stephanie22@gmail.com Marion Linn IA Chris Farmer Deb Hartz Signed (1) The employer does not elect the employers’ liability coverage. Stephanie Farmer farmer.stephanie22@gmail.com Self Marion Linn IA Chris Farmer Deb Hartz Signed
1716 2023-06-29 09:19 Anonymous (not verified) 94.188.205.169 Christine wanjiru chege Limited Liability Company 43994 w cowpath rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-29 Christine Chege christine@acuitystaffingagency.com Maricopa Pinal AZ Daniel Mwangi Anne Chege Signed (1) The employer does not elect the employers’ liability coverage. Christine chege christine@acuitystaffingagency.com Owner Maricopa Pinal AZ Daniel Mwangi Anne Chege Signed
1469 2023-02-19 18:23 Anonymous (not verified) 94.188.205.169 Superior Sheet Metal LLC Limited Liability Company 1819 MM Ave Marengo, IA 52301 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-19 Adam Lynn Nielsen adamnielsen4@yahoo.com Marengo Iowa United States Emily Jean Nielsen Joseph Daryl Kriegel Signed (1) The employer does not elect the employers’ liability coverage. Adam Lynn Nielsen adamnielsen4@yahoo.com Self Marengo Iowa Iowa Emily Jean Nielsen Joseph Daryl Kriegel Signed
1712 2023-06-26 20:33 Anonymous (not verified) 94.188.205.167 Eastern Iowa Overhead Door Proprietorship 120 N Eliza Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-26 Tim Chapin easterniadoor@gmail.com Maquoketa IA United States Carri Lee Waack Wendy Marie Zaruba Signed (1) The employer does not elect the employers’ liability coverage. Tim Chapin easterniadoor@gmail.com Owner Maquoketa Jackson United States Carri Lee Waack Wendy Marie Zaruba Signed
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
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
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
500 2021-04-29 13:09 Anonymous (not verified) 204.155.61.217 JWJ Home Remodeling LLC Limited Liability Company 16915 Weaver Lake Dr, Maple Grove MN 55311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-29 Jackson Janzen jacksonjanzen@hailmayday.com Maple Grove hennepin MN Ashley Kraft DocuSign Signed (1) The employer does not elect the employers’ liability coverage. Jackson Janzen jacksonjanzen@hailmayday.com Owner Maple Grove Hennepin MN Ashley Kraft DocuSign Signed
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
1388 2022-12-10 22:42 Anonymous (not verified) 98.156.163.144 Springfield Staffing Solution Limited Liability Company 14918 Tuff Rd, Manor TX 78653 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-10 Oluchukwu Nwokoye oly@springfieldstaffing.com Manor Travis United States Beluchukwu R Ebede Oluchukwu Nwokoye Signed (1) The employer does not elect the employers’ liability coverage. Beluchukwu Ebede admin@springfield-staffing.com Partner Manor Travis United States Beluchukwu R Ebede Oluchukwu Nwokoye Signed
280 2020-10-20 08:02 Anonymous (not verified) 98.23.12.154 Peters Painting Proprietorship 11286 290th Manning IA 51455 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-20 gregory peters rangreg@windstream.net Manning Carroll IA Amy Hansen Todd Stadtlander Signed (1) The employer does not elect the employers’ liability coverage. Gregory Peters rangreg@windstream.net self Manning Carroll IA Amy Hansen Todd Stadtlander Signed
284 2020-10-21 12:52 Anonymous (not verified) 207.177.50.27 Luke Croghan Proprietorship 2404 2200th street ,Manilla Ia. 51454 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 luke F Croghan croghanluke@gmail.com manilla Shelby Iowa Amy Hansen Todd Stadlander Signed (1) The employer does not elect the employers’ liability coverage. luke F Croghan croghanluke@gmail.com Owner manilla Shelby Iowa Amy Hansen Todd Stadlander Signed
381 2021-02-02 12:46 Anonymous (not verified) 167.142.150.21 T and A Transfer, LLC. Limited Liability Company 3330 340th 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. 2021-02-02 Todd L Ahrenholtz todd.ahrenholtz123@gmail.com Manilla IA IA Angela Ahrenholtz Angela Ahrenholtz Signed (1) The employer does not elect the employers’ liability coverage. Todd L Ahrenholtz todd.ahrenholtz123@gmail.com owner Manilla Iowa Iowa Angela Ahrenholtz Angela Ahrenholtz 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
590 2021-07-29 16:38 Anonymous (not verified) 138.43.237.95 Choice Ag Services INC Proprietorship 1841 Firefly Rd, Manchester, IA 52057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-29 Joshua Arthur Soppe choiceagservices@gmail.com Manchester Delaware Iowa Dustin Fessler Adam Reth Signed (1) The employer does not elect the employers’ liability coverage. Joshua Arthur Soppe choiceagservices@gmail.com Owner Manchester Delaware Iowa Dustin Fessler Adam Reth Signed
591 2021-07-29 16:42 Anonymous (not verified) 138.43.237.95 Choice Ag Services INC Proprietorship 1841 Firefly Rd, Manchester, IA 52057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-29 Dustin Fessler dustin@choiceagservices.com Manchester IA United States Josh Soppe Adam Reth Signed (1) The employer does not elect the employers’ liability coverage. Dustin Fessler dustin@choiceagservices.com Owner Manchester Delaware Iowa Josh Soppe Adam Reth Signed
592 2021-07-29 16:44 Anonymous (not verified) 138.43.237.95 Choice Ag Services INC Proprietorship 1841 Firefly Rd, Manchester, IA 52057 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-29 Adam Reth adam@choiceagservices.com Manchester IA United States Josh Soppe Adam Reth Signed (1) The employer does not elect the employers’ liability coverage. Adam Reth adam@choiceagservices.com Owner Manchester Delaware Iowa Josh Soppe Dustin Fessler Signed
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
91 2020-03-13 15:51 Anonymous (not verified) 173.24.190.134 Small Town RV, LLC Limited Liability Company 112 Miller Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-09 Heath Sabin sales@smalltownrv.com Mallard Palo Alto Iowa Dave Walters Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Heath Sabin sales@smalltownrv.com Member of LLC Mallard Palo Alto Iowa Dave Walters Candie Clark Signed
92 2020-03-13 15:53 Anonymous (not verified) 173.24.190.134 Tammy Sabin Limited Liability Company 112 Miller Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-09 Tammy Sabin sales@smalltownrv.com Mallard Palo Alto Iowa Dave Walters Candie Clark Signed (1) The employer does not elect the employers’ liability coverage. Tammy Sabin sales@smalltownrv.com Member of LLC Mallard Palo Alto Iowa Dave Walters Candie Clark Signed
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
980 2022-03-16 09:38 Anonymous (not verified) 207.199.231.172 Sean Wursta Proprietorship 401 Strawberry St Eddyville, IA 52553 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-16 Sean Wurstra 5wurstas@gmail.com Eddyville Mahaska Iowa James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Self 5wurstas@gmail.com self Mahaska Eddyville Iowa James Anderson Ashley Bryan Signed
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
1546 2023-03-29 20:53 Anonymous (not verified) 94.188.205.175 D2 Construction LLC Limited Liability Company 16192 Wendover Ave Madrid, Iowa 50156 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-29 Dillon Devine d2construction22@gmail.com Madrid Dallas Iowa Mark Devine Jodie Gumm Signed (1) The employer does not elect the employers’ liability coverage. Dillon Devine d2construction22@gmail.com Owner Madrid Dallas Iowa Mark Devine Jodie Gumm Signed
2113 2024-03-23 10:21 Anonymous (not verified) 94.188.205.166 D2 Construction Limited Liability Company 16192 wendover ave Madrid Ia 50156 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-23 Dillon Devine d2construction22@gmail.com Madrid Dallas Iowa Chelsey devine Jodie Gumm Signed (1) The employer does not elect the employers’ liability coverage. Dillon devine d2construction22@gmail.com Self Madrid Dallas Iowa Chelsey devine Jodie gumm Signed
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
2154 2024-04-16 08:05 Anonymous (not verified) 94.188.207.226 Lanz Pork Inc Proprietorship 12905 N 1050th Road, Macomb, IL 61455 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-02 Andrew M Riggins kellylanz1967@gmail.com Macomb IL United States Barb Coker Scott Caspall Signed (1) The employer does not elect the employers’ liability coverage. Andrew M Riggins kellylanz1967@gmail.com Self Macomb IL United States Barb Coker Scott Caspall Signed
2155 2024-04-16 08:13 Anonymous (not verified) 94.188.207.225 Andrew M Riggins Proprietorship 12905 N 1050th Road, Macomb, IL 61455 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-02 Andrew M Riggins kellylanz1967@gmail.com Macomb IL United States Barb Coker Scott Caspall Signed (1) The employer does not elect the employers’ liability coverage. Andrew M Riggins kellylanz1967@gmail.com Self Macomb IL United States Barb Coker Scott Caspall Signed
1372 2022-11-14 20:36 Anonymous (not verified) 198.14.213.147 Accurate Grading, LLC Limited Liability Company 1417 290th St Macksburg, IA 50155 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-14 Dustin A McVay dustin0980@gmail.com Macksburg IA United States Dustin A McVay Angela D McVay Signed (1) The employer does not elect the employers’ liability coverage. Dustin A McVay dustin0980@gmail.com Owner Macksburg United States Iowa Dustin A McVay Angela D McVay Signed
1483 2023-02-25 14:57 Anonymous (not verified) 94.188.205.168 Van Wyk Lawn Services Limited Liability Company 14486 S. 128th ave E. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Anthony Eugene Van Wyk vanwykturf@gmail.com Lynnville Iowa United States Ashley Lynn Van Wyk Abby Christine Peterson Signed (1) The employer does not elect the employers’ liability coverage. Anthony Eugene Van Wyk vanwykturf@gmail.com Self/Owner Lynnville Iowa United States Ashley Lynn Van Wyk Abby Christine Peterson Signed
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
182 2020-06-11 14:18 Anonymous (not verified) 173.29.64.73 Diamond Builders of Davenport INC Proprietorship 14358 275th St, Long grove, IA 52756 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-11 Paula Woods paulawoods@diamond-builders.com Long Grove IA United States Colin Woods Joe Roozeboom Signed (1) The employer does not elect the employers’ liability coverage. Tyler Green tyler@porterinsuranceinc.com Insurance Agent Long Grove IA United States Colin Woods Joe Roozeboom Signed
2034 2024-02-07 11:58 Anonymous (not verified) 94.188.207.230 Bryce Abbott Proprietorship 114 West Linn Street, Lone Tree, IA 52755 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-31 Bryce David Abbott bryceabbott86@gmail.com Lone Tree Johnson United States Dixie Abbott Andy Abbott Signed (1) The employer does not elect the employers’ liability coverage. Bryce Abbott bryceabbott86@gmail.com Self Lonetree Johnson IA Dixie Abbott Andy Abbott Signed
1634 2023-05-10 07:21 Anonymous (not verified) 94.188.205.174 KS Drywall Proprietorship 404 E Jayne Street Lone Tree, IA 52755 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-10 Kirk Strunk kirkstrunk@gmail.com Lone Tree Johnson Iowa Chris Hay Brad Bower Signed (1) The employer does not elect the employers’ liability coverage. Kirk Strunk kirkstrunk@gmail.com Self Lone Tree Johnson Iowa Chris Hay Brad Bower Signed
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
209 2020-07-19 17:02 Anonymous (not verified) 173.189.166.183 Merle Fox Proprietorship 314 N Jackson St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-19 Merle T Fox merletravisfox.79@gmail.com Lisbon Linn Iowa Dustin Ohlfest Chelsea Brown Signed (1) The employer does not elect the employers’ liability coverage. Merle Fox merletravisfox.79@gmail.com self Lisbon Linn Iowa Dustin Ohlfest Chelsea Brown Signed
293 2020-10-28 06:58 Anonymous (not verified) 173.189.165.102 Boettcher Construction Proprietorship PO Box 482, 843 West Business 30 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-28 otto p boettcher obc32@live.com Lisbon IA iowa Barb Boettcher Barb Boettcher Signed (1) The employer does not elect the employers’ liability coverage. otto p boettcher obc32@live.com same person Lisbon IA iowa Barb Boettcher Barb Boettcher Signed
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
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
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
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
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
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
1855 2023-09-27 12:56 Anonymous (not verified) 94.188.207.224 Lincoln Hotel Group Limited Liability Company 9240 Andermatt Drive Suite 1 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-27 John Edward Klimpel jklimpel@lincolnhotelgroup.com Lincoln Lancaster NE Carrie A. Fleck Jill N. Korta Signed (1) The employer does not elect the employers’ liability coverage. Brent Besch brent.besch@marshmma.com Client Lincoln Nebraska NE Carrie A Fleck Jill N Korta Signed
25 2020-01-03 13:09 Anonymous (not verified) 74.84.121.206 Raymond Jones Proprietorship P O Box 682 Monona IA 52159 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-29 Raymond Jones darrele@ciains.biz Monona Clayton Iowa Darrel J Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Darrel J Elsbernd darrele@ciains.biz insurance agent Lime Springs Howard Iowa Darrel J Elsbernd Chris Fye Signed
34 2020-01-10 15:56 Anonymous (not verified) 74.84.121.206 Milferd Loewen Proprietorship 6568 Hwy 63, Lime Springs, IA 52155 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-10 Milferd Loewen darrele@ciains.biz Lime Springs Howard Iowa Darrel J. Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Milferd Loewen darrele@ciains.biz self Lime Springs Howard Iowa Darrel J. Elsbernd Chris Fye Signed
1499 2023-03-07 11:21 Anonymous (not verified) 94.188.205.177 Ryan Zimmerman Proprietorship 17606 35th St Lime Springs, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-27 Ryan Zimmerman darrele@ciains.biz Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Darrel Elsbernd darrele@ciains.biz agent Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed
1502 2023-03-07 12:40 Anonymous (not verified) 94.188.205.177 Joseph Martin Limited Liability Company P O Box 277 Lime Springs, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-18 Joseph Martin darrele@ciains.biz Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Al's Roofing LLC darrele@ciains.biz Member Lime Springs Howard Iowa Darrel Elsbernd Chrus Fye Signed
1503 2023-03-07 12:45 Anonymous (not verified) 94.188.205.177 Al's Roofing LLC Limited Liability Company P O Box 277 Lime Springs, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-18 John Martin darrele@ciains.biz Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed (1) The employer does not elect the employers’ liability coverage. Al's Roofing LLC darrele@ciains.biz agent Lime Springs Howard Iowa Darrel Elsbernd Chris Fye Signed
2007 2024-01-29 13:13 Anonymous (not verified) 94.188.205.174 Saratoga Seamless Gutters LLC Limited Liability Company 10328 Howard Ave, Lime Springs, IA 52155 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-29 Michael Langlais saratogaseamlessgutters@gmail.com Lime Springs Howard IA Amanda Doty Michaela Langlais Signed (1) The employer does not elect the employers’ liability coverage. Michael Langlais saratogaseamlessgutters@gmail.com Owner Lime Springs Howard IA Amanda Doty Michaela Langlais Signed
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
919 2022-02-16 21:13 Anonymous (not verified) 208.126.203.31 K & D Land Improvement, LLC Limited Liability Company 2719 270th Street, Lehigh, Iowa 50557 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-16 Daniel Hansen dhansen@lvcta.com Lehigh Webster Iowa Karen Hansen Cathy Mickelson Signed (1) The employer does not elect the employers’ liability coverage. Daniel Hansen dhansen@lvcta.com Member Lehigh Webster Iowa Karen Hansen Cathy Mickelson Signed
2210 2024-05-07 19:15 Anonymous (not verified) 94.188.207.229 Greenelectric Proprietorship 407 Drury Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-07 Harold Carr handbcarr@hotmail.com Legrad Iowa Iowa Harold Dale Carr Harold Dale Carr Signed (1) The employer does not elect the employers’ liability coverage. Harold Carr handbcarr@hotmail.com I am the owner Legrad Iowa Iowa Harold Dale Carr Harold Dale Carr 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
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
1242 2022-08-03 14:53 Anonymous (not verified) 107.141.197.247 Hygieia Stainless Solutions LLC Limited Liability Company 2200 Blairsferry Crossing Hiawatha, IA 52233 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-03 Kevin R Dibel kevin.dibel@hygieiastainless.com Lebanon Wilson Tennessee Andy Scanlon Roger Batterson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Kevin R Dibel kevin.dibel@hygieiastainless.com self Lebanon Wilson Tennessee Andy Scanlon Roger Batterson Signed
791 2021-12-14 11:35 Anonymous (not verified) 108.178.194.186 Leaf Home solutions LLC Limited Liability Company 1595 Georgetown rd. Hudson OH 44236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-14 Abelardo Lino Montes alinomontes@gmail.com Le claire IA 52753 Scott Iowa Ann Pelton Herman Roche Signed (1) The employer does not elect the employers’ liability coverage. Abelardo Lino Montes alinomontes@gmail.com Owner Le Claire Scott IA Ann Pelton Herman Roche Signed
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
1013 2022-03-28 14:54 Anonymous (not verified) 74.115.101.41 Curt Hudson DBA C & L Trucking Partnership 44651 120th Ave Laurens, IA 50554 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 Curtis Hudson clhudson@ncn.net Laurens Pocahonta IA Dale Eng Troy Rubel Signed (1) The employer does not elect the employers’ liability coverage. Curtis Hudson clhudson@ncn.net self Laurens Pocahontas IA Dale Eng Troy Rubel Signed
1394 2022-12-14 14:31 Anonymous (not verified) 74.84.121.206 Benjamin Salo Proprietorship 320 Plat St Lansing, IA 52151 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-09 Benjamin Salo benwa011@gmail.com Lansing, Iowa Allamakee Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Benjamin Salo benwa011@gmail.com self Lansing Allamakee Iowa Chris Fye Darrel Elsbernd Signed
1979 2024-01-08 14:59 Anonymous (not verified) 94.188.205.167 Nathan Troendle Proprietorship Lansing Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-05 Nathan Troendle darrele@ciains.biz Lansing Allamakee Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Nathan Troendle darrele@ciains.biz self Lansing Allamakee Iowa Chris Fye Darrel Elsbernd Signed
2112 2024-03-22 08:22 Anonymous (not verified) 94.188.205.174 WR TREE SERVICES Limited Liability Company 1176 highway 9 Lansing iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-22 Wesley Adam Remund wesleyadamremund@gmail.com Lansing Allamakee Iowa JENNIFER K Harris Stefan M Remund Signed (1) The employer does not elect the employers’ liability coverage. Wesley Adam Remund wesleyadamremund@gmail.com OWNER Lansing Allamakee Iowa Jennifer K Harris Stefan M Remund Signed
1885 2023-10-29 08:05 Anonymous (not verified) 94.188.207.223 MB Radon Services Limited Liability Company 13206 State Hwy 2, Lamoni, Iowa, 50140 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-29 Kyle Ramaeker raymaker83@gmail.com LAMONI IA United States Adam Boge Lance Webster Signed (1) The employer does not elect the employers’ liability coverage. Kyle Ramaeker raymaker83@gmail.com Owner/Operator LAMONI IA United States Adam Boge Lance Webster Signed
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
65 2020-02-18 15:44 Anonymous (not verified) 70.58.180.91 TD & I CABLE MAINTENANCE INC. Proprietorship P.O. BOX 266 LAKELAND MN. 55043 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-18 FREDERICK W GREEN FREDGREENCONSTRUCTION@YAHOO.COM DES MOINES POLK IOWA KATHYRN EILEEN WILLIAMSON MICHAEL BOYD WILLIAMS Signed (1) The employer does not elect the employers’ liability coverage. LIZZY SHEPARD LIZZYSHEPARD@TDICABLE.COM SUBCONTRACTOR LAKELAND WASHINGTON MINNESOTA KATHRYN EILEEN WILLIAMSON MICHAEL BOYD WILLIAMS Signed
1136 2022-05-31 13:46 Anonymous (not verified) 173.31.148.43 OKOBOJI BURRITO COMPANY LLC Limited Liability Company 39502 710TH ST LAKEFIELD, MN 56105 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-26 KATHRYN SCHULTZ kathrynlucier@ymail.com LAKEFIELD JACKSON MN JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. KATHRYN SCHULTZ kathrynlucier@ymail.com SELF LAKEFIELD JACKSON MN JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
2027 2024-02-07 09:24 Anonymous (not verified) 94.188.207.228 RB SIDING Proprietorship P.O. BOX 2034, 310 370TH STREET, LAKE VIEW, IOWA 51450 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 ROBERT BELT bridgetbelt1971@outlook.com SELF SAC IOWA JOHN CLARENCE OLERICH NEIL THIESSEN MARTENS Signed (1) The employer does not elect the employers’ liability coverage. ROBERT EUGENE BELT bridgetbelt1971@outlook.com SELF LAKE VIEW SAC IOWA JOHN CLARENCE OLERICH NEIL THIESSEN MARTENS Signed
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
2035 2024-02-07 12:34 Anonymous (not verified) 94.188.205.176 WAYNE GRAFFUNDER Proprietorship 3244 358TH STREET, LAKE VIEW, IOWA 51450 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 WAYNE ALLEN GRAFFUNDER hdbearhunter@gmail.com LAKE VIEW SAC IOWA JOHN CLARENCE OLERICH ROBERT EUGENE BELT Signed (1) The employer does not elect the employers’ liability coverage. WAYNE ALLEN GRAFFUNDER hdbearhunter@gmail.com SELF LAKE VIEW SAC IOWA JOHN CLARENCE OLERICH ROBERT EUGENE BELT Signed
95 2020-03-18 14:47 Anonymous (not verified) 173.24.186.251 Layton C. Vick II dba Layton's Backhoe Service Proprietorship PO Box 652 / Spirit Lake, IA 51360 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-18 Layton Clarence VIck II lcvii2@gmail.com Lake Park Dickinson Iowa Daniel Reimers Marcus VanKleek Signed (1) The employer does not elect the employers’ liability coverage. Layton C. Vick II lcvii2@gmail.com Owner Lake Park Dickinson Iowa Daniel Reimers Marcus VanKleek Signed
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
1037 2022-04-07 08:16 Anonymous (not verified) 104.207.27.18 SION LUTHERAN CHURCH Proprietorship 4525 FINCH AVE LAKE MILLS, IA 50450 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-07 JANE BRUNSVOLD janebrunsvold@yahoo.com LAKE MILLS WINNEBAGO IOWA ANDREW STENSRUD JILL FLUGUM Signed (1) The employer does not elect the employers’ liability coverage. ANDREW STENSRUD ANDREW@STENSRUDINSURANCE.COM INSURANCE AGENT LAKE MILLS WINNEBAGO IOWA JANE BRUNSVOLD JILL FLUGUM Signed
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
1482 2023-02-24 13:57 Anonymous (not verified) 94.188.205.175 Vaughn Seeds, LLC Limited Liability Company 5025 13th Ave, La Porte City, IA 50651 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-24 Brice Jacob Vaughn brice.vaughn1@gmail.com La Porte Citty Benton Iowa Abby Jo Rolston Jessica Lyn McCabe Signed (1) The employer does not elect the employers’ liability coverage. Abby Rolston arolston@hagerins.net Insured La Porte City Black Hawk Iowa Jessica Lyn McCabe Russell Britson Signed
468 2021-04-12 14:54 Anonymous (not verified) 173.27.224.230 PCI Turf LLC Limited Liability Company 1313 N Grant St. Knoxville, IA 50138 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-12 Ryan Trout rtrout22@yahoo.com Knoxville Marion Iowa Joseph Durham Carson Peterson Signed (1) The employer does not elect the employers’ liability coverage. Ryan Trout pci.turf@yahoo.com Self- owner/operator Knoxville Marion Iowa Joseph Durham Carson Peterson Signed
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
1146 2022-06-07 11:51 Anonymous (not verified) 173.27.226.177 Evans Endeavors LLC Limited Liability Company 513 N Roche St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-07 Cody Evans evansendeavor@gmail.com Knoxville Marion Iowa Erin Six Carl stoffer Signed (1) The employer does not elect the employers’ liability coverage. Cody Evans evansendeavor@gmail.com Myself Knoxville Marion Iowa Erin six Carl Stoffer Signed
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
115 2020-04-09 11:42 Anonymous (not verified) 67.60.46.104 D&H Plumbing, L.L.C Limited Liability Company 44214 260th St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-05 Delwayne Merrill Abbott del_abbott@yahoo.com Kingsley Plymouth Iowa Doug Alan Gerdes Nick William Lahrs Signed (1) The employer does not elect the employers’ liability coverage. Delwayne Merrill Abbott brettherbold@gmail.com Owner Kingsley Plymouth Iowa Doug Alan Gerdes Nick William Lahrs Signed
1954 2023-12-13 13:51 Anonymous (not verified) 94.188.207.227 Beeson Trucking LLC Limited Liability Company 219 Tilden St Kingsley IA 51028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-13 Jeremy Beeson jeremy4k78@yahoo.com Kingsley Plymouth IA Katherine Weaver Darla Robley Signed (1) The employer does not elect the employers’ liability coverage. Jeremy Beeson jeremy4k78@yahoo.com Self Kingsley Plymouth IA Katherine Weaver Darla Robley Signed
116 2020-04-09 11:45 Anonymous (not verified) 67.60.46.104 D&H Plumbing, L.L.C Limited Liability Company 44214 260th St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-05 Brett Alan Herbold brettherbold@gmail.com Remsen Plymouth Iowa Doug Alan Gerdes Nick Willam Lahrs Signed (1) The employer does not elect the employers’ liability coverage. Delwayne Merrill Abbott brettherbold@gmail.com Owner Kinglsey Plymouth Iowa Doug Alan Gerdes Nick William Lahrs Signed
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
652 2021-09-22 21:52 Anonymous (not verified) 209.152.66.250 Robert Stutzman Limited Liability Company 33784 Hwy 22 Keota, IA 25548 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-22 Robert L Stutzman bnbstutzman@gmail.com Keota Keokuk Iowa Jo Edgington Amber Gent Signed (1) The employer does not elect the employers’ liability coverage. Sandra K Stutzman iafarmgirl90@gmail.com Daughter Keota Keokuk Iowa Jo Edgington Amber Gent Signed
855 2022-01-26 10:39 Anonymous (not verified) 209.152.66.250 Robert L Stutzman Limited Liability Company 33784 Hwy 22 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-26 Robert L Stutzman bnbstutzman@gmail.com Keota Iowa United States Dasha Hesseltine Janette Miller Signed (1) The employer does not elect the employers’ liability coverage. Sandra Stutzman iafarmgirl90@gmail.com Daughter Keota Iowa United States Dasha Hesseltine Janette Miller Signed
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
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
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
205 2020-07-15 14:19 Anonymous (not verified) 108.209.12.64 Sequoia integrative Medical Services Limited Liability Company 1746 Paul Drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-15 Jennifer Christine VandenHeuvel jvandenheuvel@att.net Kaukauna WI United States David VandenHeuvel Pam Leplavy Signed (1) The employer does not elect the employers’ liability coverage. Jennifer Christine VandenHeuvel jvandenheuvel@att.net Owner Kaukauna WI United States David VandenHeuvel Pam Leplavy Signed
1305 2022-09-13 14:28 Anonymous (not verified) 166.181.82.226 MarDe's construction Limited Liability Company 5381 16th Ave la porte city ia 50651 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-13 Dean Michael John Martells deanmartells@gmail.com La porte city Benton Ia Sonya Alfreda Mounlavong Cameron Michael Martells Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Regional recruiter Kansas city, mo Clay Missouri Jordan Nisiewicz Jordan Loyd Signed
1344 2022-10-25 13:09 Anonymous (not verified) 69.76.241.21 Tom Cole Proprietorship 742 Mill St. Council, 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. 2022-10-25 Tom Cole tcoleg1963@gmail.com Council Bluffs, IA Pottawattamie County, IA Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Regional Recruiter Kansas City, MO Clay Missouri Jordan Nisiewicz Jordan Loyd Signed
1722 2023-07-06 10:57 Anonymous (not verified) 94.188.205.169 Brother’s Handyman Services LLC Proprietorship 1270 A Avenue, Marion, IA 52302, 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. 2023-07-06 Tyler Dahl handybros39@gmail.com Marion, IA Linn County Iowa Jordan Nisiewicz Charles Woods Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City, MO Johnson Missouri Charles Woods Jordan Loyd Signed
665 2021-10-06 09:22 Anonymous (not verified) 192.96.173.171 Michael Childers Proprietorship 21 N.6th street savanna Illinois I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-06 Michael Childers peddler73@hotmail.com Savanna Carroll Illinois Brandy arnold Jordan nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Jordan nisiewicz jnisiewicz@leafhome.com Recruiter Kansas city Clay Mo Jordan nisiewicz Brandy arnold Signed
750 2021-11-16 12:34 Anonymous (not verified) 172.58.83.130 Austin Carlson Proprietorship 1341 iron city avenue atalissa Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-16 Austin Carlson toppeakconstruction@gmail.com Atalissa Muscating Iowa Jordan Nisiewicz Sam Apponey Signed (1) The employer does not elect the employers’ liability coverage. Jorden Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Jackson Missouri Jordan Nisiewicz Sam Apponey Signed
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
1339 2022-10-18 14:14 Anonymous (not verified) 97.125.41.64 Juan Buenrostro Proprietorship 2122 E 39th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-18 Juan Buenrostro juanjosebuenrostro@gmail.com Des Moines Polk IA Juan Buenrostro Kelly gonzalez buenrostro Signed (1) The employer does not elect the employers’ liability coverage. Jordan nisiewicz jnisiewicz@leafhome.com Regional recruiter Kansas City Clay Missouri Jordan nisiewicz Jordan loyd Signed
1363 2022-11-08 11:37 Anonymous (not verified) 69.76.241.21 S&M Veteran Contracting Proprietorship 1529 E Ave NW Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-08 Shane Little smveterancontracting@gmail.com Cedar Rapids Linn County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Regional Recruiter Kansas City Clay MO Jordan Loyd Joshua Lafond Signed
1378 2022-11-21 15:12 Anonymous (not verified) 136.34.59.85 Jake Jones Proprietorship 203 9th Ave. Colona, Il 61241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-21 Jake Jones jmjones807@gmail.com Colona Henry Illinois Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Regional Recruiter Kansas City Clay Missouri Jordan Loyd Daniel Neal Signed
1391 2022-12-12 11:13 Anonymous (not verified) 136.35.255.41 Snyder Roofing Proprietorship 2343 ridge trail ne cedar rapids ia 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-12-12 Craig Snyder snyderroofingcr@gmail.com Cedar Rapids Linn county Iowa Jordan Loyd Charles Wood Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Charles Wood Jordan Loyd Signed
1429 2023-01-25 13:43 Anonymous (not verified) 136.35.255.41 J&D Renovations Proprietorship 114 2nd St. Carbon Cliff, IL 61239 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-25 Donald Lane jdrenovations309@gmail.com Carbon Cliff, IL Rock Island County Illinois Jordan Nisiewicz Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Cody Dubar Signed
1453 2023-02-14 07:19 Anonymous (not verified) 94.188.207.230 Milton Gray Proprietorship 255 10th Ave., Marion, IA 52302, US I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-13 Milton Gray miltongray23@gmail.com Marion, IA Linn Iowa Jordan Nisiewicz Charles Wood Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay MO Charles Wood Steven Geisler Signed
1513 2023-03-13 06:54 Anonymous (not verified) 94.188.205.169 Tyler Ankney Proprietorship 1250 A Avenue, Marion, IA 52302, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-13 Tyler Ankney T_james55@ahoo.com Marion Linn County Iowa Jordan Nisiewicz Steve Gisler Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Steve Gisler Signed
1563 2023-04-11 08:49 Anonymous (not verified) 94.188.205.168 Ibrahim Sehic Proprietorship 4052 Lafayette Rd, Evansdale, IA 50707 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-11 Ibrahim Sehic bacosidig@gmail.com Evansdale, IA Black Hawk County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Warren Crow Signed
1564 2023-04-11 09:15 Anonymous (not verified) 94.188.205.174 Darryl Kinnard Proprietorship 60 Miller Avenue Southwest #13, Cedar Rapids, IA 52404, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-11 Darryl Kinnard darryl186d@icloud.com Cedar Rapids Linn County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Robert Snyder Signed
1566 2023-04-12 08:40 Anonymous (not verified) 94.188.205.169 Sabokwigura Jonathan Proprietorship 1613 12th Avenue Southeast, Cedar Rapids, IA 52401, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-12 Sabokwigura Jonathan nzobojo@gmail.com Cedar Rapids Linn County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Robert Snyder Signed
1593 2023-04-24 09:41 Anonymous (not verified) 94.188.207.225 Tyler Wilson Proprietorship 5319 Ruhd Street Southwest, Cedar Rapids, IA 52404, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-24 Tyler Wilson t.wilson237@gmail.com Cedar Rapids Linn Missouri Jordan Loyd Jordan Nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Robert Snyder Signed
1594 2023-04-24 10:06 Anonymous (not verified) 94.188.205.175 Joseph Hatton Proprietorship 85 Cardinal Ave, Atkins , 52206, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-24 Joseph Hatton joeyh697@gmail.com Atkins Benton County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Robert Snyder Signed
1620 2023-05-01 08:03 Anonymous (not verified) 94.188.207.228 Devon Willis Proprietorship 401 West 1st Street, Mechanicsville, IA 52306, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-01 Devon Willis willisbaseball2@gmail.com Mechanicsville, IA Cedar Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Missouri Clay Jordan Loyd Robert Snyder Signed
1629 2023-05-09 08:50 Anonymous (not verified) 94.188.207.223 Alex Jones Proprietorship 2423 Glass Road Northeast, Cedar Rapids, IA 52402, United State I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-09 Alex Jones ajones0425@yahoo.com Cedar Rapids Linn Iowa Jordan Nisiewicz Charles Wood Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Jordan Loyd Charles Wood Signed
1630 2023-05-09 08:54 Anonymous (not verified) 94.188.207.225 Ronald McChane Proprietorship 400 Lewellen dr nw, CEDAR RAPIDS, IA 52405, US I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-09 Ronald McChane rws79213@gmail.com Cedar Rapids Linn Iowa Jordan Nisiewicz Charles Woods Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Iowa Charles Woods Jordan Loyd Signed
1685 2023-06-12 07:21 Anonymous (not verified) 94.188.207.224 Steven Boshart Proprietorship 2172 Scales Bend Road Northeast, North Liberty, IA 52317, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-12 Steven Boshart sboshart1982@gmail.com North Liberty, MO Johnson Iowa Jordan Nisiewicz Charles Wood Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Charles Wood Jordan Loyd Signed
1686 2023-06-12 07:45 Anonymous (not verified) 94.188.207.229 Robert Burman Proprietorship 400 Lindale Dr 119 Marion, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-11 Robert Burman robertburman791@gmail.com Marion Linn Iowa Charles Wood Jordan Nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Charles Wood Jordan loyd Signed
1709 2023-06-26 14:55 Anonymous (not verified) 94.188.205.177 Jeremy Pledge Proprietorship 3310 East Washington Street, Iowa City, IA 52245 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-26 Jeremy Pledge worknoplay8@gmail.com Iowa City, IA Johnson County Iowa Jordan Nisiewicz Charles Wood Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Charles Woods Jordan Loyd Signed
1794 2023-08-10 14:56 Anonymous (not verified) 94.188.205.169 Alex Kiler Proprietorship 10511 Main Road, La Porte City, IA 50651, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-10 Alex Kiler alexkiler12622@gmail.com La Porte City, IA Black Hawk County Iowa Charles Woods Steve Geisler Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Charles Wood Steven Geisler Signed
1820 2023-08-28 08:12 Anonymous (not verified) 94.188.205.177 LLAD Services LLC Limited Liability Company 1611 Esplanade Avenue Davenport IA 52803 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-28 Austin Lee Terry austinfarrell92@gmail.com Davenport Scott Iowa Cody Dunbar Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz JNisiewicz@leafhome.com Recruiter Kansas City Clay Missouri Cody Dunbar Jordan Loyd Signed
1828 2023-09-06 14:43 Anonymous (not verified) 94.188.205.177 Des Moines Smart Solutions LLC. Proprietorship 1329 56th st, Des Moines, IA 50311, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-06 Denzel Colocho alejandro_colcho@yahoo.com Des Moines, IA Polk Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay MO Jordan Loyd Charles Wood Signed
1854 2023-09-27 11:22 Anonymous (not verified) 94.188.205.174 Wen Boatwright Proprietorship 4200 Indianola Ave Des Moines, IA 50320 United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-27 Wen Boatwright wenboatwrght@gmail.com Des Moines Des Moines Iowa Jordan Nisiewicz Cody Dunbar Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson Missouri Jordan Loyd Cody Dunbar Signed
1857 2023-10-02 16:33 Anonymous (not verified) 94.188.205.169 Noah Blount Proprietorship 2611 capitol ave, Des Moines, IA 50317, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-02 Noah Blount nbeav5@gmail.com Des Moines Des Moines Iowa Jordan Loyd Charles Woods Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Jackson Missouri Jordan Loyd Charles Woods Signed
2012 2024-01-31 10:38 Anonymous (not verified) 94.188.207.228 Mathew Soulis Proprietorship 618 Boston Drive, Davenport, IA 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-31 Mathew Soulis mathew.soulis@gmail.com Davenport Scott IA Jordan Nisiewicz Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz JNisiewicz@leafhome.com Recruiter Kansas City Johnson MO Cody Dunbar Monica Acosta Signed
2047 2024-02-15 16:58 Anonymous (not verified) 94.188.205.177 PorchLight Insights LLC Limited Liability Company 2918 Campbell Street, Kansas City, MO 64109 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-15 Kate Regnier Bender kate.bender@porchlightinsights.com Kansas City Jackson Missouri Jonathan Bender Brandon Steenson Signed (1) The employer does not elect the employers’ liability coverage. Kate Regnier Bender kate.bender@porchlightinsights.com Co-Founder Kansas City Jackson Missouri Jonathan Bender Brandon Steenson Signed
2053 2024-02-22 11:29 Anonymous (not verified) 94.188.205.166 Demir sehic Proprietorship 4052 Lafayette road I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-22 Demir Sehic Demirsehic123@gamil.com Waterloo IA United States Jordan nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan nisiewicz jnisiewicz@leafhome.com Recurring Kansas city Jackson Mo Demir sehic Jordan Loyd Signed
2116 2024-03-27 09:53 Anonymous (not verified) 94.188.205.175 Purdy Pretty Projects inc Proprietorship 5380 13 ave, La porte city, IA 50651, US I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-27 Chad Purdy redtactor12345@gmail.com La porte city LaPorte County Iowa Jordan Nisiewicz Jordan Loyd Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson Missouri Jordan Loyd Warren Crow Signed
2135 2024-04-04 11:02 Anonymous (not verified) 94.188.207.227 Jonathan Warner Proprietorship 420 16th Avenue, East Moline, IL 61244, US I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-04 Jonathan Warner bsguttersllc@gmail.com East Moline, IL Moline Illinois Jordan Nisiewicz Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson MO Jordan Loyd Cody Dunbar Signed
2151 2024-04-15 14:42 Anonymous (not verified) 94.188.207.227 Jose Acuna Proprietorship 1015 East Main Street, Belmond, IA 50421, US I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-15 Jose Acuna Joseacuna@gmail.com Belmond, IA Wright Iowa Jordan Loyd Jordan Nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Johnson Missouri Jordan Loyd Cody Dunbar Signed
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
2216 2024-05-09 11:51 Anonymous (not verified) 94.188.207.229 Imhoff Innovations LLC Limited Liability Company 108 Cherry Lane 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. 2024-05-09 Jediah Imhoff jedimhoff@gmail.com Riverside IA United States Jordan Nisiewicz Jordan Lyod Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Regional Recruiter Kansas City Johnson MO Jordan Lyod Jediah Imhoff 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
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
859 2022-01-27 11:29 Anonymous (not verified) 204.155.61.217 JD Drywall Proprietorship 503 9th Street Kalona, Iowa 52247 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-27 John Duwa johnduwa@outlook.com Kalona Washington Iowa Angela Stutzman Jeff Spenner Signed (1) The employer does not elect the employers’ liability coverage. JD Drywall - John Duwa johnduwa@outlook.com owner Kalona Washington Iowa Angela Stutzman Jeff Spenner Signed
892 2022-02-03 15:52 Anonymous (not verified) 204.155.61.217 JD DRYWALL Proprietorship 503 9th Street Kalona, Iowa 52247 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-03 John Duwa johnduwa@outlook.com Kalona Washington Iowa Jeff Spenner Angela Stutzman Signed (1) The employer does not elect the employers’ liability coverage. JD Drywall - John Duwa johnduwa@outlook.com owner Kalona Washington Iowa Jeff Spenner Angela Stutzman Signed
955 2022-03-08 11:21 Anonymous (not verified) 166.181.80.171 JB Roofing & Home Repair Limited Liability Company 453 South Street Kalona, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-08 Jason Boller jbroofhr@gmail.com Kalona Washington IA Jodee Stransky Christian Swartzentruber Signed (1) The employer does not elect the employers’ liability coverage. Christian Swartzentruber christian@fisherins.com Insurance Agent Kalona Washington IA Jodee Stransky Christian Swartzentruber Signed
1347 2022-10-26 14:42 Anonymous (not verified) 173.21.223.66 Mid American Roofing Limited Liability Company 811 8th St Kalona IA 52247 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-26 Josiah Hoyt midamericanroofing@gmail.com KALONA IA United States Jensen Ropp Randy Ropp Signed (1) The employer does not elect the employers’ liability coverage. Josiah Hoyt josiahhoyt@gmail.com Owner KALONA IA United States Jensen Ropp Randy Ropp Signed
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
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
1318 2022-09-22 11:18 Anonymous (not verified) 50.82.91.213 J. Thompson Builders, LLC Limited Liability Company 5291 Stoney Creek Ct. Johnston, IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-22 Christopher Jacob Von Arx cjvonarx@hotmail.com Van Wert IA Decatur IA Iowa Christina Viehauser Jeremy Thompson Signed (1) The employer does not elect the employers’ liability coverage. Christina Viehauser christina@jthompsonbuilders.com Office Help Johnston Ia Polk IA Chris Von Arx Jeremy Thompson Signed
1319 2022-09-22 11:31 Anonymous (not verified) 50.82.91.213 J. Thompson Builders, LLC Limited Liability Company 5291 Stoney Creek Ct. Johnston, IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-22 Mark Grant mjgrant1957@gmail.com Adel Dallas IA Christina Viehauser Jeremy Thompson Signed (1) The employer does not elect the employers’ liability coverage. Christina Viehauser christina@jthompsonbuilders.com Office Help Johnston Ia Polk IA Chris Von Arx Jeremy Thompson Signed
663 2021-10-04 09:45 Anonymous (not verified) 166.181.80.1 Matthew Winters Proprietorship 9220 Summit Dr Johnston IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-04 Matthew Winters mattwinters55@gmail.com Johnston Polk Iowa Brittany Strub Judy Sansom Signed (1) The employer does not elect the employers’ liability coverage. Matthew Winters mattwinters55@gmail.com Self Johnston Polk Iowa Brittany Strub Judy Sansom Signed
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
687 2021-10-22 11:07 Anonymous (not verified) 65.144.174.26 Fernando Garcia Proprietorship 8952 Long Meadow Dr Johnston, IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-22 Fernando Garcia gfernando5030@gmail.com johnston polk Iowa Javier Manriquez Josefina Chavez Signed (1) The employer does not elect the employers’ liability coverage. Fernando Garcia gfernando5030@gmail.com Owner Johnston Polk Iowa Javier Manriquez Josefina Chavez Signed
929 2022-02-18 09:18 Anonymous (not verified) 174.198.74.217 LA Painting LLC Limited Liability Company 6460 Merle Hay Rd unit 222 Johnston, IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-18 Adolfo Rodriguez Afanador adolforodriguez11@yahoo.com Johnston Polk Iowa Esequiel Rodriguez Karina Valdez Signed (1) The employer does not elect the employers’ liability coverage. Adolfo Rodriguez Afanador adolforodriguez11@yahoo.com Owner Johnston Polk Iowa Esequiel Rodriguez Karina Valdez Signed
1169 2022-06-23 16:23 Anonymous (not verified) 159.45.71.17 Whitlow Remodeling and Home Services, LLC Limited Liability Company 6421 NW 54th Ct Johnston Iowa 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 Scot Alan Whitlow resaw375@msn.com Johnston Polk Iowa Erin Scanlan Charles Thorn Signed (1) The employer does not elect the employers’ liability coverage. Scot Alan Whitlow resaw375@msn.com Owner Johnston Polk Iowa Erin Scanlan Charles Thorn Signed
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
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
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
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
94 2020-03-18 13:18 Anonymous (not verified) 174.243.114.80 Sogard Excavating Limited Liability Company 2374 380th St, Jewell, IA 50130 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-18 Jon A Sogard jsogard22@gmail.com Jewell Hamilton IA Fallon Sogard Julee Lund Signed (1) The employer does not elect the employers’ liability coverage. Sogard Excavating LLC jsogard22@gmail.com owner Jewell Hamilton IA Fallon Sogard Julee Lund Signed
837 2022-01-13 08:38 Anonymous (not verified) 169.197.65.8 Reyes Concrete Services llc Limited Liability Company 101 Perry St South Jesup, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-13 Ronald Reyes ronlreyes1975@gmail.com Jesup Buchanan Iowa Jacolin Reyes Ronald Reyes Signed (1) The employer does not elect the employers’ liability coverage. Ronald Reyes ronlreyes1975@gmail.com Same Jesup Buchanan Iowa Jacolin Reyes Ronald Reyes Signed
1094 2022-05-12 09:26 Anonymous (not verified) 173.30.136.186 Missy Weber Limited Liability Company 4290 Spring Creek Road Jesup, Iowa 50648 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-12 Melissa Weber mweber@cardinalcapital.us JESUP Black Hawk Iowa Sharon Woodson Shelly Donlon Signed (1) The employer does not elect the employers’ liability coverage. Jeff Weber mweber@cardinalcapital.us partner/husband Jesup Blackhawk Iowa Janice Weber Laverne Weber Signed
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
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
2166 2024-04-20 13:38 Anonymous (not verified) 94.188.205.175 Cedar Valley Seamless, LLC Limited Liability Company 1184 215th St, Jesup, IA 50648 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-20 Andrew Richard Trumbauer cedarvalleyseamlessllc@gmail.com Jesup Buchanan Iowa James William Masteller Andrew William Hamilton Signed (1) The employer does not elect the employers’ liability coverage. Andrew Richard Trumbauer cedarvalleyseamlessllc@gmail.com Owner/Operator Jesup Buchanan Iowa James William Masteller Andrew William Hamilton Signed
199 2020-07-09 10:49 Anonymous (not verified) 167.142.98.40 Ryan Stott Proprietorship 1513 Hawthorne Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Ryan Lynn Stott rlstott@hotmail.com Jefferson Greene Iowa Brock Chisum Brian Chisum Signed (1) The employer does not elect the employers’ liability coverage. Ryan Stott rlstott@hotmail.com self Jefferson Greene Iowa Brock Chisum Brian Chisum Signed
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
527 2021-05-20 07:54 Anonymous (not verified) 66.43.242.142 mcconnells custom construction Proprietorship 1074 240th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-01 John McConnell jnkatmcc@netins.net jefferson greene ia Jordan Hostetler Mark Aspengren Signed (1) The employer does not elect the employers’ liability coverage. McConnell's Custom Construction jnkatmcc@netins.net owner jefferson greene ia Jordan Hostetler Mark Aspengren Signed
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
939 2022-02-28 13:46 Anonymous (not verified) 173.23.228.17 H & T Ziesman, LLC Limited Liability Company 575 Nuthatch Iowa Falls IA 50126 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-28 Heath Ziesman heathziesman87@gmail.com Iowa Falls Franklin Iowa Jeanne Rieks Kelly Reed Signed (1) The employer does not elect the employers’ liability coverage. Heath ZIesman heathziesman87@gmail.com Owner Iowa Falls Franklin Iowa Jeanne Rieks Kelly Reed Signed
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
69 2020-02-19 15:58 Anonymous (not verified) 198.14.241.59 MORENOS C ROOFING LLC Limited Liability Company 2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-19 RAQUEL OLEA CAMACHO JORGETREJO19896@GMAIL.COM IOWA CITY JOHNSON IOWA JORGE TREJO JOSE SALGADO Signed (1) The employer does not elect the employers’ liability coverage. RAQUEL OLEA CAMACHO JORGETREJO19896@GMAIL.COM OWNER IOWA CITY JOHNSON IOWA JORGE TREJO JOSE SALGADO Signed
84 2020-02-28 15:30 Anonymous (not verified) 198.167.182.164 Rid-A-Bird Inc. Limited Liability Company 3116 Friendship St. Iowa City IA 52245 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-28 Keith Wilson kwilson@windowgenie.com Iowa City Johnson Iowa Dyan Kriener Marcia A Colvin Signed (1) The employer does not elect the employers’ liability coverage. Keith Wilson kwilson@windowgenie.com Managing member Iowa City Johnson Iowa Dyan Kriener Marcia A Colvin Signed