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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:
39 2020-01-19 11:00 Anonymous (not verified) 75.163.84.145 Allen L Bryen Proprietorship 2609 Madison St Bellevue NE 68005 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-19 Allen Lee Bryen Allen.Bryen@yahoo.com Bellevue Sarpy Nebraska Jeffrey Coats Donald Coats Signed (1) The employer does not elect the employers’ liability coverage. Allen L Bryen Allen.Bryen@yahoo.com Self Bellevue Sarpy Nebraska jeffrey Coats Donald Coats Signed
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
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
2117 2024-03-27 10:38 Anonymous (not verified) 94.188.207.226 ALCON CONSTRUCTION LLC Limited Liability Company 2613 GINDY DR, BELLEVUE, NE 68147 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-27 VALERIE OLONO ALCONCONSTRUCTION2021@GMAIL.COM BELLEVUE SARPY NEBRASKA VICTOR H OLONO GANDARILLA ALEXANDRA GUTIERREZ Signed (1) The employer does not elect the employers’ liability coverage. VALERIE OLONO ALCONCONSTRUCTION2021@GMAIL.COM SELF BELLEVUE SARPY NEBRASKA VICTOR H OLONO GANDARILLA ALEXANDRA GUTIERREZ Signed
1939 2023-12-05 14:32 Anonymous (not verified) 94.188.207.229 PJ Trucking Unlimited LLC Limited Liability Company 2617 380th Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-05 Peggy Jensen pegandhalj@gmail.com Farragut US IA Darlene Julie Ann Marshsll Signed (1) The employer does not elect the employers’ liability coverage. Peggy Jensen pegandhalj@gmail.com self Farragut US IA Darlene Carpenter Julie Marshall Signed
254 2020-09-10 20:13 Anonymous (not verified) 97.127.219.61 Scott Woodward Proprietorship 2619 west 69th St. davenport Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-10 Scott Woodward woodwardscott2001@gmail.com Davenport Scott Iowa Scott Woodward Scott Woodward Signed (1) The employer does not elect the employers’ liability coverage. Scott Woodward woodwardscott2001@gmail.com Self employed Davenport Scott Iowa Scott Woodward Scott Woodward Signed
128 2020-04-24 14:14 Anonymous (not verified) 173.21.123.73 JLC Finish Trim Carpenter inc Proprietorship 2620 61st st des moines iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-24 aura cordova mendoza isabel_menro81@yahoo.com des moines polk iowa emily segura roslyn duenas Signed (1) The employer does not elect the employers’ liability coverage. Jose Mendoza jlctrimcarpenterinc@gmail.com employer des moines polk iowa emily segura roslyn duenas Signed
1048 2022-04-14 14:17 Anonymous (not verified) 208.38.229.255 Mean Green Lawn Care Limited Liability Company 2628 W 59th st Davenport Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Anthony mccash meangreenlawncare20@gmail.com Davenport Scott Iowa Clarissa Oliva Julie Thornman Signed (1) The employer does not elect the employers’ liability coverage. Anthony McCash meangreenlawncare20@gmail.com Owner Davenport Scott Iowa Clarissa Oliva Julie Thornman Signed
1091 2022-05-06 09:54 Anonymous (not verified) 97.127.228.168 American Concrete Proprietorship 2629 Sheffield dr. Davenport iowa 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Craig wells craiglwells@hotmail.com Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed (1) The employer does not elect the employers’ liability coverage. DK home products anne@dkhomeproducts.com Sub contractor Davenport Scott Iowa Kristin frymoyer Cameron anderson Signed
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
1612 2023-04-27 10:37 Anonymous (not verified) 94.188.207.223 Grind Works LLC Proprietorship 26416 289th place Unit H Adel IA 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-27 Adam Samuelson Hello@grindworksia.com Adel Dallas Iowa Chandler Clark Adam Samuelson Signed (1) The employer does not elect the employers’ liability coverage. Adam Samuelson Hello@Grindowrksia.com N/A Adel Dallas Iowa Adam Samuelson Chandler Clark Signed
1786 2023-08-07 05:08 Anonymous (not verified) 94.188.205.169 Ph Construction Limited Liability Company Limited Liability Company 2643 Beaver Ave Suite 105 Des Moines Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-07 Patricia Ann Hook patricia.diverseconstruction@gmail.com Des Moines United States United States Allen W Butts Kate Ridge Signed (1) The employer does not elect the employers’ liability coverage. Patricia Ann Hook patricia.diverseconstruction@gmail.com Self - Owner Des Moines United States Iowa Allen W Butts Kate Ridge Signed
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
1996 2024-01-24 10:30 Anonymous (not verified) 94.188.207.224 E&p quality home remodeling llc Limited Liability Company 2660 NE 44th ct desmoines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-24 Pedro martinez pmsalas82@gmail.com Des Moines Polk Iowa Rogelio martinez Rigoberto martinez Signed (1) The employer does not elect the employers’ liability coverage. Pedro Martinez pmsalas82@gmail.com Owner Des Moines Polk Iowa Rogelio Martínez Rigoberto Martínez Signed
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
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
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
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
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
836 2022-01-12 19:41 Anonymous (not verified) 170.178.244.191 BVH Trucking LLC Limited Liability Company 26826 210th Ave Eldridge IA 852748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-12 Brandon Venhorst avenhorst@csteldridge.com Eldridge Scott IA Annette Venhorst Scott Venhorst Signed (1) The employer does not elect the employers’ liability coverage. Brandon Venhorst avenhorst@csteldridge.com Owner Eldridge Scott IA Annette Venhorst Scott Venhorst Signed
843 2022-01-20 07:48 Anonymous (not verified) 207.199.230.75 Heart of Iowa Inspections LLC Limited Liability Company 2700 Highway 63 Oskaloosa, Iowa 52577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-20 Randy DeHeer rdenheer2828@gmail.com Oskaloosa Mahaska Iowa Cheryl Brown Doris Crile Signed (1) The employer does not elect the employers’ liability coverage. Randy DeHeer rdenheer2828@gmail.com self Oskaloosa Mahaska Iowa Cheryl Brown Doris Crile Signed
934 2022-02-23 12:13 Anonymous (not verified) 207.199.230.75 Randy DeHeer Limited Liability Company 2700 Highway 63 Oskaloosa, Iowa 52577 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-23 Randy DeHeer rdeheer2828@gmail.com Oskaloosa Mahaska Jowa Cheryl Brown Doris Crile Signed (1) The employer does not elect the employers’ liability coverage. Randy DeHeer rdeheer2828@gmail.com Self Oskaloosa Mahaska Iowa Cheryl Brown Doris Crile Signed
180 2020-06-09 13:35 Anonymous (not verified) 99.203.113.208 Z & Sons handyman company LLC Limited Liability Company 2701 E Market St Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-09 Miguel Angel Zuniga mazuniga123678@gmail.com Des Moines Polk Iowa Rosario Zuniga Christina Zuniga Signed (1) The employer does not elect the employers’ liability coverage. Miguel Angel Zuniga mazuniga123678@gmail.com Z & Sons handyman company LLC is owned by agent Des Moines Polj Iowa Rosario Zuniga Christina Zuniga Signed
181 2020-06-09 20:44 Anonymous (not verified) 75.162.15.198 Z & Sons handyman company LLC Limited Liability Company 2701 E Market St Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-09 Miguel Angel Zuniga mazuniga123678@gmail.com Des Moines Polk Iowa Rosario Zuniga Christina Zuniga Signed (1) The employer does not elect the employers’ liability coverage. Miguel Angel Zuniga mazuniga123678@gmail.com Z & Sons handyman company LLC is owned by agent Des Moines Polk Iowa Rosario Zuniga Christina Zuniga Signed
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
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
2224 2024-05-15 11:22 Anonymous (not verified) 94.188.207.224 Community Centered Counseling Services, LLC Limited Liability Company 2711 W 63rd St Ste 3 Davenport, IA 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-26 Adam Vilmont avilmont@cccs.me Davenport Scott Iowa Briane Franks Amanda Tesch Signed (1) The employer does not elect the employers’ liability coverage. Adam Vilmont avilmont@cccs.me Self Davenport Scott Iowa Briane Franks Amanda Tesch 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
1150 2022-06-10 16:14 Anonymous (not verified) 173.29.125.38 Vernon Tim McClain Limited Liability Company 2717 Thompson ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-10 Vernon Tim McClain mcclainlawn@gmail.com Des Moines POlk Iowa Ilisha Carter Earl Warren Jr. Signed (1) The employer does not elect the employers’ liability coverage. vernon mcclain mcclainlawn@gmail.com business owner des moines polk iowa Ilisha Carter Earl Warren Jr. 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
444 2021-03-22 16:26 Anonymous (not verified) 207.191.204.10 Robert G. Wright Jr, Proprietorship 2721 Elm St Dubuque, IA 52001 PO Box 475 Dubuque, IA 52004 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-20 Robert G. Wright Jr, robertw1963@gmail.com Dubuque Dubuque Iowa Brian Kregal Lynda Howell Signed (1) The employer does not elect the employers’ liability coverage. Robert G. Wright Jr, robertw1963@gmail.com Owner Dubuque Dubuque Iowa Brian Kregel Lynda Howell Signed
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
1359 2022-11-04 10:48 Anonymous (not verified) 173.18.22.217 Lewis Enterprises Limited Liability Company 2723 Witmer Street Des Moines Ia 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-04 Corey Lewis coreyboy1990@gmail.com Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Corey Lewis coreyboy1990@gmail.com Owner Des Moines Polk Iowa Kelly Coluzzi Erick Schuldt Signed
808 2021-12-20 12:28 Anonymous (not verified) 107.77.209.143 Painting & Design Proprietorship 2728 51st Des Moines Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-20 John Eugene Herman jherman30@yahoo.com Des moines Polk Iowa Peggy Noplos Jennifer Herman Signed (1) The employer does not elect the employers’ liability coverage. John Herman jherman30@yahoo.com Self Des moines Polk Iowa Peggy Noplos Jennifer Herman Signed
2051 2024-02-16 17:40 Anonymous (not verified) 94.188.205.174 Ryans Outdoor Services LLC Limited Liability Company 2731 Pinard St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-16 Ryan Carroll ryancarrolls1226@icloud.com Dubuque Dubuque Iowa Rob McDonald Philip Grommet Signed (1) The employer does not elect the employers’ liability coverage. Ryan Carroll ryancarrolls1226@icloud.com Self Dubuque Dubuque Iowa Rob McDonald Philip Grommet Signed
1784 2023-08-04 10:39 Anonymous (not verified) 94.188.205.175 Danny Davis Limited Liability Company 2733 Raccoon Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-04 Danny R Davis ddavis3243@yahoo.com Des Moines IA United States Michael Gatewood Brad Wheeler Signed (1) The employer does not elect the employers’ liability coverage. HD EXTERIORS LLC ddavis3243@yahoo.com Owner Des Moines IA United States Michael Gatewood Brad Wheeler Signed
560 2021-07-08 08:46 Anonymous (not verified) 66.188.136.150 Darius Harvey Proprietorship 2738 E 53rd. Apt. 7 Davenport, IA 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-07 Darius Harvey kschumacher@tricorinsurance.com Davenport Scott IA Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Darius Harvey kschumacher@tricorinsurance.com Same Davenport Scott IA Mitch Kemp Shuree Behr Signed
1076 2022-04-28 13:14 Anonymous (not verified) 149.20.212.228 Van Ginkel Farms LLC Limited Liability Company 2745 Chestnut Ave Inwood, IA 51240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 James Van Ginkel bonnievanginkel@gmail.com Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed (1) The employer does not elect the employers’ liability coverage. James VanGinkel bonnievanginkel@gmail.com self Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed
1077 2022-04-28 13:16 Anonymous (not verified) 149.20.212.228 Van Ginkel Farms LLC Limited Liability Company 2745 Chestnut Ave Inwood, IA 51240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Bonnie VanGinkel bonnievanginkel@gmail.com Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed (1) The employer does not elect the employers’ liability coverage. James VanGinkel bonnievanginkel@gmail.com owner Inwood Lyon Iowa Jesse Niemeyer Jaslyn VanOtterloo Signed
1642 2023-05-12 07:29 Anonymous (not verified) 94.188.205.169 HARI SWAMI LLC Limited Liability Company 2759 Mt Pleasant St, Burlington, IA 52601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-12 BRANDON KELLY MARKWILLIAMSPRO@GMAIL.COM FRUIT HEIGHTS DAVIS UTAH MARK WILLIAMS GREG VANCAMP Signed (1) The employer does not elect the employers’ liability coverage. BRANDON KRLLY MARKWILLIAMSPRO@GMAIL.COM SELF FRUIT HEIGHTS DAVIS UTAH MARK WILLIAMS GREG VANCAMP Signed
1769 2023-07-31 11:23 Anonymous (not verified) 94.188.207.228 PSI LLC Limited Liability Company 2765 N Center Point Rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-31 Esteici Reyes stacy0979@gmail.com Cedar Rapids Linn IA Jeffrey Ventura Eduardo Contreras Signed (1) The employer does not elect the employers’ liability coverage. Esteici Reyes stacy0979@gmail.com Owner Cedar Rapids Linn IA Jeffrey Ventura Eduardo Contreras Signed
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
1652 2023-05-17 20:44 Anonymous (not verified) 94.188.205.167 Fox Trucking Proprietorship 2774 March Ave Greene Ia. 50636 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-17 Chet D. Fox cjakfox@yahoo.com Greene Floyd Iowa Jack Dwyer Chad Olson Signed (1) The employer does not elect the employers’ liability coverage. Chet Fox cjakfox@yahoo.com myself Greene Floyd Iowa Jack Dwyer Chad Olson Signed
236 2020-08-18 16:15 Anonymous (not verified) 173.28.28.57 Michael Ballhagen Proprietorship 279 Pine Street, Allison IA 50602 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-07 Michael Ballhagen cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Michael Ballhagen cmins_re@mchsi.com Self Allison Butler Iowa Chad Campbell Roxanne Kolder Signed
323 2020-11-19 10:55 Anonymous (not verified) 174.192.67.61 Connor trucking Proprietorship 2791 270th st Dewitt ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-19 Richard Todd Connor connortrucking@hotmail.com Dewitt Clinton Iowa Michelle Connor Josh connor Signed (1) The employer does not elect the employers’ liability coverage. Richard Todd Connor connortruckin@hotmail.com Self Dewitt Clinton Iowa Michelle Connor Josh Connor Signed
186 2020-06-15 08:03 Anonymous (not verified) 66.188.136.150 Candace Dingler Proprietorship 280 Trimble Station Road I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-10 Candace Dingler kschumacher@tricorinsurance.com Hogansville Troup GA Russell Masartis Angie Ords Signed (1) The employer does not elect the employers’ liability coverage. Candace Dingler kschumacher@tricorinsurance.com Same Hogansville Troup GA Russell Masartis Angie Ords Signed
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
212 2020-07-20 16:43 Anonymous (not verified) 97.64.164.30 Bernard L. Gradoville D.D.S. Proprietorship 2800 Ingersoll Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-20 Bernard Gradoville bgradoville@ingersollfamilydentistry.com Des Moines IA United States Tricia Wilson Jack Gradoville Signed (1) The employer does not elect the employers’ liability coverage. Bernard Gradoville bgradoville@ingersollfamilydentistry.com self Des Moines IA United States Tricia Wilson Jack Gradoville Signed
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
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
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
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
2230 2024-05-16 16:15 Anonymous (not verified) 94.188.205.175 Hagerty LLC Proprietorship 2816 Highway 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. 2024-05-16 RYAN JOESPH HAGERTY hagertyllc@gmail.com Muscatine IA United States Mary Wetzel Misty Wetzel Signed (1) The employer does not elect the employers’ liability coverage. RYAN JOESPH HAGERTY hagertyllc@gmail.com owner of llc Muscatine IA United States Mary Wetzel Misty Wetzel Signed
1507 2023-03-09 08:16 Anonymous (not verified) 94.188.207.230 Greufe Construction Proprietorship 2820 230th 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. 2023-01-01 Wayne Greufe wgreufe@wmtel.net Blairsburg US United States Janet Greufe Janet Greufe Signed (1) The employer does not elect the employers’ liability coverage. Wayne Greufe wgreufe@wmtel.net Friend Blairsburg US United States Janet Greufe Janet Greufe 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
1100 2022-05-13 12:54 Anonymous (not verified) 50.83.96.157 Spindrift LLC Limited Liability Company 2825 Newport Rd NE Iowa City IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-13 Nathaniel James Dooley spindriftlawnandsnow@gmail.com Iowa City Johnson Iowa Sharon Dooley Kristen Simpson Signed (1) The employer does not elect the employers’ liability coverage. Nathaniel James Dooley spindriftlawnandsnow@gmail.com Same Iowa City Johnson Iowa Sharon Dooley Kristen Simpson Signed
1191 2022-07-07 12:15 Anonymous (not verified) 207.177.48.254 Day Ag Service LLC Proprietorship 28250 240th Street Dallas Center, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-07 Calvin Brewer Day cal.d.day@gmail.com Dallas Center Dallas IA Dale Day Mary Beth Day Signed (1) The employer does not elect the employers’ liability coverage. Calvin Brewer Day cal.b.day@gmail.com Self Dallas Center Dallas IA Dale Day Mary Beth Day Signed
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
1568 2023-04-12 10:46 Anonymous (not verified) 94.188.205.175 Daniel gramowski Limited Liability Company 2835 raccoon street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-12 Daniel gramowski oneanddoneroofing@gmail.com Des moines Polk Iowa Paige gramowski Cole smith Signed (1) The employer does not elect the employers’ liability coverage. Daniel gramowski oneanddoneroofing@gmail.com Owner Des Moines Polk Iowa Cole smith Paige gramowski Signed
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
542 2021-06-16 07:26 Anonymous (not verified) 173.23.202.34 Russell’s lawn & landscape Limited Liability Company 285 robins rd, Hiawatha unit C16 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-16 Johnoy Khalil Russell johnoyjrrussell@gmail.com Hiawatha Linn Iowa Adrian pink Rupert Ellis Signed (1) The employer does not elect the employers’ liability coverage. Johnoy Khalil russell johnoyjrrussell@gmail.com Owner Hiawatha Linn Iowa Rupert ellis Adrian pink Signed
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
1736 2023-07-11 08:30 Anonymous (not verified) 94.188.207.228 Scornos Waukee LLC Limited Liability Company 286 w hickman rd waukee iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Liana Fatino lfatino@yahoo.com des moines polk iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Liana Fatino lfatino@yahoo.com owner des moines polk IOWA Liana Fatino Gary Fatino Signed
1737 2023-07-11 08:32 Anonymous (not verified) 94.188.207.223 Scornos waukee llc Limited Liability Company 286 w hickman rd waukee iowa 50263 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Gary Fatino fatinomarketinggroup@yahoo.com des moines polk iowa Liana Fatino Gary Fatino Signed (1) The employer does not elect the employers’ liability coverage. Gary Fatino fatinomarketinggroup@yahoo.com owner des moines polk iowa Liana Fatino Gary Fatino Signed
1765 2023-07-27 14:27 Anonymous (not verified) 94.188.207.225 Midwest Systems Proprietorship 2877 130th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-27 Matt Griswold midwestsystems@live.com Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed (1) The employer does not elect the employers’ liability coverage. Matt Griswold midwestsystems@live.com Owner Aurora IA United States Creatleigh Griswold Carslyn Griswold Signed
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
1279 2022-08-22 13:17 Anonymous (not verified) 50.83.54.168 Essex Family Construction Limited Liability Company 290 Monmouth St SW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-22 Niki Essex essexfamilycontruction@outlook.com Cedar Rapids IA IA Josh Lasond Jordan Nisiewicz Signed (1) The employer does not elect the employers’ liability coverage. Niki Essex essexfamilycontruction@outlook.com same Cedar Rapids Iowa Iowa Josh Lasond Jordan Nisiewicz Signed
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
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
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
289 2020-10-23 14:42 Anonymous (not verified) 65.103.82.36 Go Green Lawn and Tree Proprietorship 2911 N Harrison st Davenport IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-23 Brandon gogreenlawnandtree@yahoo.com davenport scott iowa Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. brandon gordon gogreenlawnandtree@yahoo.com self davenport scott ia kayla eric Signed
1178 2022-07-05 12:02 Anonymous (not verified) 172.58.122.51 Wright home restoration Limited Liability Company 2914 South Union St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-05 Matthew Wright wright.home.restoration@gmail.com Des Moines IA United States Jane wright Robert wright Signed (1) The employer does not elect the employers’ liability coverage. Wright home restoration wright.home.restoration@gmail.com Myself Des Moines IA United States Jane wright Robert Wright Signed
625 2021-08-30 20:39 Anonymous (not verified) 173.16.140.101 Phthalo Consulting LLC Limited Liability Company 2917 47th St, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-30 Angela Stone-Wiegert angela@phthaloconsulting.com Des Moines Polk Iowa Sonya Shippy Kenny Shippy Signed (1) The employer does not elect the employers’ liability coverage. Angela Stone-Wiegert angela@phthaloconsulting.com Owner Des Moines Polk Iowa Sonya Shippy Kenny Shippy Signed
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
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
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
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
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
203 2020-07-15 09:39 Anonymous (not verified) 166.181.66.222 High Caliber Fiber Limited Liability Company 2958 110th ave masonville IA, 50654 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-15 Chris cooper chris_cooper@highcaliberfiber.com Masonville Delaware Iowa Nick beranek Nicole kintzle Signed (1) The employer does not elect the employers’ liability coverage. Chris Cooper chris_cooper@highcaliberfiber.com N/A Masonville Delaware Iowa Nick beranek Nicole kintzle Signed
1160 2022-06-20 10:08 Anonymous (not verified) 138.43.237.249 High Caliber Fiber Limited Liability Company 2958 110th ave masonville IA, 50654 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-20 chris cooper Chris_cooper@highcaliberfiber.com Masonville Delaware IA Laura Rose Lentz Blake Dean Elbert Signed (1) The employer does not elect the employers’ liability coverage. Chris Cooper Chris_cooper@highcaliberfiber.com self Masonville Delaware IA Laura Rose Lentz BLake Dean Elbert Signed
1138 2022-06-01 15:01 Anonymous (not verified) 173.18.233.175 Roy Rohwedder Proprietorship 296 24th Ave SW Cedar Rapids, IA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-01 Roy h Rohwedder rohwedder.roy@yahoo.com Cedar Rapids linn iowa Cash Rohwedder Brian Ashlock Signed (1) The employer does not elect the employers’ liability coverage. Brian Ashlock brian@tricounty-iowa.com Genaral Manager Cedar Rapids Linn IOWA Branden Peters Jenny Vaske Signed
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
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
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
285 2020-10-21 16:24 Anonymous (not verified) 66.188.136.150 Roger Cole Proprietorship 30 Devon Dr. Dubuque, IA 52001 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-21 Roger cole kschumacher@tricorinsurance.com Dubuque Dubuque IA Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Roger Cole kschumacher@tricorinsurance.com Same Dubuque Dubuque IA Russell Masartis Nancy Wortley Signed
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
1625 2023-05-04 14:07 Anonymous (not verified) 94.188.207.228 Extreme Repair, LLC Limited Liability Company 300 North Carthage St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-04 Tony Cleveland extremerepair1@yahoo.com EXIRA, IA Audubon United States Katherine Cleveland Isaac Kommes Signed (1) The employer does not elect the employers’ liability coverage. Extreme Repai,r LLC extremerepair1@yahoo.com Self EXIRA, IA Audubon United States Katherine Cleveland Isaac Kommes Signed
1396 2022-12-19 18:35 Anonymous (not verified) 174.198.65.20 Flyover Productions LLC Limited Liability Company 300 S Clinton St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-19 Richard A Redfern richredfern3@gmail.com Iowa City IA United States Susan Redfern Aditi Reddy Signed (1) The employer does not elect the employers’ liability coverage. Richard Redfern richredfern3@gmail.com Owner of company Iowa City Iowa United States Susan Redfern Aditi Reddy Signed
1455 2023-02-15 11:44 Anonymous (not verified) 94.188.205.177 Bruce A. Nelson Proprietorship 300 Shetland Dr Nw Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-15 Bruce A. Nelson sherylnelson15@yahoo.com Cedar Rapids Linn Iowa Lynn M Haigh David Reibsamen Signed (1) The employer does not elect the employers’ liability coverage. Sheryl Nelson sherylnelson15@yahoo.com Wife Cedar Rapids Linn Iowa Lynn M. Haigh David Reibsamen Signed
1332 2022-10-12 20:44 Anonymous (not verified) 209.252.174.114 Nelson Tile Proprietorship 300 Shetland Dr. N.W. Cedar Rapids, Ia. 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-12 Bruce Allen Nelson sherylnelson15@yahoo.com Cedar Rapids Linn Iowa Sheryl Marie Nelson Roger Eugene Nelson Signed (1) The employer does not elect the employers’ liability coverage. Bruce Allen Nelson sherylnelson@yahoo.com Owner,operator / same Cedar Rapids Linn Iowa Sheryl Marie Nelson Roger Eugene Nelson Signed
272 2020-10-02 13:10 Anonymous (not verified) 99.203.92.229 Batres Homes Renovation LLC Limited Liability Company 3000 2nd Ave Des Moines Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-02 Gabriel Antonio Batres Huezo gabirlebatres7@gmail.com Des Moines Polk Iowa Blanca Silvia Leiva Luis Mariano Signed (1) The employer does not elect the employers’ liability coverage. Walter Alexander Batres Huezo wbatres12@gmail.com Employer Des Moines Polk Iowa Blanca Silvia Leiva Luis Mariano Signed
2221 2024-05-13 09:26 Anonymous (not verified) 94.188.207.226 Chad matthews Proprietorship 3000 Justin dr. Suite J I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-05-13 Chad matthews kaceno2269@gmail.com Urbandale IA United States Sheri Frazier Terry warren Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Chad Matthews kaceno2269@gmail.com None Urbandale IA United States Sheri Fraiser Terry Warren Signed
1969 2023-12-28 15:46 Anonymous (not verified) 94.188.205.176 Beau Vander Sluis Proprietorship 3000 Seneca Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-28 Beau Vander Sluis beauvsluis@gmail.com Des Moines Polk United States Braden Banning Andrew Behanish Signed (1) The employer does not elect the employers’ liability coverage. Beau Vander Sluis beauvsluis@gmail.com Same Des Moines Polk United States Braden Banning Andrew Behanish Signed
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
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
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
1771 2023-08-01 09:59 Anonymous (not verified) 94.188.207.223 Modern Builder LLC Limited Liability Company 30008 560th St Chariton IA 50049 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-01 Tatyana Sayenko modernbuilder02@gmail.com Chariton Lucas Iowa Arthur Sayenko Viktor Sayenko Signed (1) The employer does not elect the employers’ liability coverage. Tatyana Sayenko modernbuilder02@gmail.com owner/ Family Chariton Lucas Iowa Arthur Sayenko Viktor Sayenko Signed
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
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
1914 2023-11-20 16:05 Anonymous (not verified) 94.188.207.227 Dark Horse Transport LLC Limited Liability Company 301 Lincoln St, Brayton, IA 50042 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-20 James William Meese bethany.dhtllc@gmail.com Brayton Audubon Iowa Hayley Meese-Cherry Wyatt Jessen Signed (1) The employer does not elect the employers’ liability coverage. James Wiliam Meese bethany.dhtllc@gmail.com Owner Brayton Audubon Iowa Hayley Meese-Cherry Wyatt Jessen Signed
1693 2023-06-16 11:37 Anonymous (not verified) 94.188.207.230 Anthony Scroggins Proprietorship 301 SE 11th Street , Unit 807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-16 Anthony Scroggins scroggins710@gmail.com Grimes Polk IA Cody Wavada Nate Duden Signed (1) The employer does not elect the employers’ liability coverage. Anthony Scroggins scroggins710@gmail.com Self Grimes Polk IA Cody Wavada Nate Duden Signed
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
318 2020-11-16 15:06 Anonymous (not verified) 50.82.130.211 Boulder Woodworks, LLC Limited Liability Company 3011 Boulder Drive, Cedar Falls IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-28 Eric Simmons cmins_re@mchsi.com Cedar Falls Black Hawk Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Eric Simmons cmins_re@mchsi.com Self Cedar Falls Black Hawk Iowa Chad Campbell Roxanne Kolder Signed
294 2020-10-28 10:08 Anonymous (not verified) 65.103.82.36 Des Moines Junk Proprietorship 3011 Dean Ave Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-31 Timothy Hall Sr. removal@dsmjunk.com Des Moines Polk Iowa eric johnson kayla artiolo Signed (1) The employer does not elect the employers’ liability coverage. Tim Hall removal@dsmjunk.com self des moines polk Iowa eric Kayla 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
547 2021-06-24 08:05 Anonymous (not verified) 97.125.169.60 Tenant Improvement Services, LLC Limited Liability Company 3011 Justin Drive, Urbandale, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-24 Josh Chiles josh@tenantimprovementsiowa.com Des Moines Polk Iowa John Martin Johnny Holman Signed (1) The employer does not elect the employers’ liability coverage. Josh Chiles josh@tenantimprovementsiowa.com Member Des Moines Polk Iowa John Martin Johnny Holman Signed
1158 2022-06-17 06:34 Anonymous (not verified) 97.125.255.177 Zach Ellis Proprietorship 3013 Se Stoneridge St Grimes ia 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-17 Zachary Ellis zach2865@gmail.com Grimes IA United States Brittany Klien Kennedy Ellis Signed (1) The employer does not elect the employers’ liability coverage. Zachary Ellis zach2865@gmail.com Myself Grimes Polk Iowa Brittany Klien Kennedy Ellis 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
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
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
1098 2022-05-12 17:54 Anonymous (not verified) 199.66.15.123 Timothy W Robinson Proprietorship 302 N Kenwood blvd Indianola IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-12 Timothy William Robinson williamswork18@gmail.com Indianola Warren Iowa Sarah Anne Robinson Andrew Gilbert Barber Signed (1) The employer does not elect the employers’ liability coverage. Timothy William Robinson williamswork18@gmail.com Sole proprietor Indianola Warren Iowa Sarah Anne Robinson Andrew Gilbert Barber Signed
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
360 2021-01-12 12:08 Anonymous (not verified) 75.162.189.102 Super Green Plus Llc Limited Liability Company 3020 SE 5th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-12 Damon Berry theatvfan@gmail.com Des Moines IA United States Naki Brown Nakima Brown Signed (1) The employer does not elect the employers’ liability coverage. Super Green Plus theatvfan@gmail.com owner Des Moines IA United States Naki Brown Nakima Brown Signed
440 2021-03-18 08:11 Anonymous (not verified) 66.188.136.150 Jeffrey Gardner Proprietorship 3020 W 1st St., Davenport, IA 52804 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-17 Jeffrey Gardner kschumacher@tricorinsurance.com Davenport Polk IA Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Jeffrey Gardner kschumacher@tricorinsurance.com Same Davenport Polk IA Russell Masartis Shuree Behr Signed
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
2124 2024-03-28 13:47 Anonymous (not verified) 94.188.207.225 Gudiel Construction & Masonry LLC Limited Liability Company 303 Lacona Ave Des Moines Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-28 Santiago Gudiel Lopez gudielsantiago972@gmail.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Santiago Gudiel Lpez gudielsantiago972@gmail.com Self Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
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
484 2021-04-16 10:58 Anonymous (not verified) 66.188.136.150 Erick Hodges Proprietorship 3039 Magnolia Dr. Bettendorf, IA 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-16 Erick Hodges kschumacher@tricorinsurance.com Bettendorf Scott IA Jordan Bass Russell Masartis Signed (1) The employer does not elect the employers’ liability coverage. Erick Hodges kschumacher@tricorinsurance.com Same Bettendorf Scott IA Jordan Bass Russell Masartis Signed
297 2020-10-30 10:43 Anonymous (not verified) 216.51.132.207 Kregel Farm Partnership Limited Liability Partnership 30392 Garber RD Guttenberg, IA 52052 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-08 Travis Kregel TRAVIS.KREGEL@GMAIL.COM Garber Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Travis Kregel TRAVIS.KREGEL@GMAIL.COM owner Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
298 2020-10-30 10:45 Anonymous (not verified) 216.51.132.207 Kregel Farm Partnership LLP Limited Liability Partnership 30392 Garber RD Guttenberg, IA 52052 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-08 Gary Kregel TRAVIS.KREGEL@GMAIL.COM Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Gary Kregel TRAVIS.KREGEL@GMAIL.COM same Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
299 2020-10-30 10:47 Anonymous (not verified) 216.51.132.207 Kregel Farm Partnership LLP Limited Liability Partnership 30392 Garber RD Guttenberg, IA 52052 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-09 Darlene Kregel TRAVIS.KREGEL@GMAIL.COM Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Darlene Kregel TRAVIS.KREGEL@GMAIL.COM owner Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
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
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
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
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
1277 2022-08-22 08:57 Anonymous (not verified) 68.169.247.177 Andrew Betts Proprietorship 305 3rd ave sw cascade ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-22 Andrew Betts dbidrywallco@gmail.com Cascade Dubuque Iowa Jamie manternach Andy hall Signed (1) The employer does not elect the employers’ liability coverage. Andrew Betts dbidrywallco@gmail.com Owner Cascade Iowa United States Jamie manternach Andy hall Signed
2031 2024-02-07 10:54 Anonymous (not verified) 94.188.207.224 PETER MARTENS Proprietorship 305 4TH STREET NORTH, ALBERT CITY, IOWA 50510 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 PETER KLASSEN MARTENS pkmmartens@hotmail.com ALBERT CITY BUENA VISTA IOWA ROBERT EUGENE BELT JOHN CLARENCE OLERICH Signed (1) The employer does not elect the employers’ liability coverage. PETER KLASSEN MARTENS pkmmartens@hotmail.com SELF ALBERT CITY SAC IOWA ROBERT EUGENE BELT JOHN CLARENCE OLERICH Signed
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
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
1911 2023-11-15 20:39 Anonymous (not verified) 94.188.205.174 Bkauzie-LLC dba CR Painting Limited Liability Company 3051 104th St Suite A Urbandale IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-15 Brian Kauzlarich brian@crpaintingdsm.com Altoona Polk Iowa Ryan Thompson Rylie Thompson Signed (1) The employer does not elect the employers’ liability coverage. Brian Kauzlarich brian@crpaintingdsm.com owner/self Altoona Polk Iowa Ryan Thompson Rylie Thompson Signed
951 2022-03-05 07:53 Anonymous (not verified) 207.32.3.98 Larson Transport Systems Limited Liability Company 3055 Maple Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-05 Spencer Larson spenlarson@gmail.com Forest City IA United States Mike Larson Sandy Larson Signed (1) The employer does not elect the employers’ liability coverage. Spencer Larson spenlarson@gmail.com owner Forest City IA United States Mike Laron Sandy Larson Signed
1562 2023-04-10 07:43 Anonymous (not verified) 94.188.205.174 JB Concrete and Construction Limited Liability Company 306 1st Ave N.W Dayton Ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-10 JaredBerglund jaredberglund71@gmail.com Dayton Webster Iowa Travis Sonksen Chase Haman Signed (1) The employer does not elect the employers’ liability coverage. JaredBerglund jaredberglund71@gmail.com Owner Dayton Webster Iowa Travis Sonksen Chase Haman Signed
1379 2022-11-22 11:44 Anonymous (not verified) 166.181.89.236 365 Services LLC Limited Liability Company 306 hayes st e hazleton iowa 50641 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-22 Clayton marshall davis Lcrc365@outlook.com Hazleton Bucanan Iowa Grace lilibridge Kurt king Signed (1) The employer does not elect the employers’ liability coverage. Clayton marshall davis Lcrc365@outlook.com Owner Hazleton Bucanan Iowa Kurt kind Grace lilibridge Signed
1698 2023-06-20 16:43 Anonymous (not verified) 94.188.205.167 Mike farrell Proprietorship 306 ne trilein dr ankeny,ia 50021 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-20 Michael David farrell farrellsfmr@yahoo.com Ankeny Polk Ia ERICK SCHULST Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Michael David farrell farrellsfmr@yahoo.com Owner Ankeny Polk Iowa Erick Schuldr Kelly .Coluzzi3 Signed
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
1197 2022-07-11 08:35 Anonymous (not verified) 107.127.35.22 Leaf Filter Limited Liability Partnership 3060 SE Grimes Blvd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 Jacqueline Martínez charamusca05erick@icloud.com West Des Moines United Stated Iowa Melvin Gomez Martín Martínez Signed (1) The employer does not elect the employers’ liability coverage. Leaf Filter support@leafhome.com Sub contractor Grimes United States Iowa Melvin Gomez Martín Martínez Signed
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
1694 2023-06-16 14:37 Anonymous (not verified) 94.188.205.176 Leaf Home Solutions LLC Partnership 3060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-16 Caleb Brincks chbrincks@gmail.com 628 NE 56th St Ankeny IA, 50021 Polk County Iowa Melissa Brincks Anisha Moten Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. AFTON INC chbrincks@gmail.com Owner Ankeny Polk Iowa Melissa Brincks Anisha Moten Signed
1233 2022-07-28 22:53 Anonymous (not verified) 166.181.84.53 Leaffilter Limited Liability Company 3060 SE Grimes Blvd Suite 100-300, Grimes, IA 501113060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-28 Mohammed Albayati mrcarbody.81@gmail.com Johnston Polk Iowa Tammy Decker Waffa Albayati Signed (1) The employer does not elect the employers’ liability coverage. Meghan Mcilhon mmcilhon@leaffilter.com Human Resources Grimes Polk Iowa Tammy Decker Waffa Albayati Signed
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
731 2021-11-09 14:08 Anonymous (not verified) 166.181.87.107 Leaf Filter North Limited Liability Company 3060 SE Grimes Blvd, STE 100 Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-09 Jordan Cunningham jcunnsalvage@gmail.com Baxter Jasper Iowa Karen Cunningham Makenzie Raridon Signed (1) The employer does not elect the employers’ liability coverage. Megan McIlhon mmcilhon@leaffilter.com Office Manager Grimes Polk Iowa Karen Cunningham Makenzie Raridon Signed
1177 2022-07-05 10:01 Anonymous (not verified) 172.58.85.103 Leaf Guard Limited Liability Partnership 3060 SE Grimes Blvd, suite 100 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-04 Sean Gray Totaldemo94@gmail.com Des Moines Polk county Iowa Jeanie Lu Terra McAllister Signed (1) The employer does not elect the employers’ liability coverage. Leaffilter North LLC leaffilter@leafhome.com Worker Des moines Polk county IA Jeanie Lu Terra McAllister Signed
660 2021-09-30 14:15 Anonymous (not verified) 172.58.86.219 LeafFilter Limited Liability Company 3060 SE Grimes Blvd. Suite 100-300, Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-30 Mohammed Albayati mmm2002faris@yahoo.com West Des Moines Polk Iowa Tammy Decker Yaseen Albayati Signed (1) The employer does not elect the employers’ liability coverage. Mohammed Albayati albayatim28@gmail.com Employee Grimes Polk Iowa Tammy Decker Yaseen Albayati Signed
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
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
603 2021-08-14 09:39 Anonymous (not verified) 173.20.168.51 Leaf Filter Proprietorship 3060 Southeast Grimes Boulevard I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-08-14 Francisco Salgado fsalgado1989@gmail.com Perry IA United States Wendy Asturias Susana Romero Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Leaf Filter macosta@leafhome.com none Grimes Polk Iowa Wendy Asturias Susana Romero Signed
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
1163 2022-06-23 09:17 Anonymous (not verified) 74.84.106.106 James Chitty Proprietorship 307 2nd St Colo, Ia 50056 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 James Chitty techsupport@smartind.com Colo Story IA Tina Owens Kim Owens Signed (1) The employer does not elect the employers’ liability coverage. James Chitty techsupport@smartind.com self Colo Story IA Tina Owens Kim Owens Signed
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
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
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
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
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
977 2022-03-15 12:04 Anonymous (not verified) 38.108.136.192 Gunner Fogle Proprietorship 307 S. Franklin St. Corydon, IA 50060 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Gunner Lee Fogle gunnerfogle@hotmail.com Corydon Wayne IA Jeremy Fogle Erika Fogle Signed (1) The employer does not elect the employers’ liability coverage. Gunner Fogle gunnerfogle@hotmail.com Myself Corydon Wayne IA Jeremy Fogle Erika Fogle Signed
810 2021-12-22 15:13 Anonymous (not verified) 167.142.30.134 Bouillon Lawn Care Proprietorship 3074 Lodge Ave Greene, IA 50636 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-22 Jerry Bouillon greeneflowerman@yahoo.com Greene Floyd Iowa Lucas Wedeking Misty Osborn Signed (1) The employer does not elect the employers’ liability coverage. Jerry Bouillon Greeneflowerman@yahoo.com Self Greene Floyd Iowa Lucas Wedeking Misty Osborn Signed
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
2060 2024-02-28 09:36 Anonymous (not verified) 94.188.207.228 BRANDON LEHNER Proprietorship 308 SANFORD STREET ARCHER IA 51231 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-28 BRANDON LEHNER BLEHNER302@GMAIL.COM ARCHER OBRIEN IA TAMI KLEIN JOSEPH LORING Signed (1) The employer does not elect the employers’ liability coverage. BRANDON LEHNER BLEHNER302@GMAIL.COM SELF ARCHER OBRIEN IA TAMI KLEIN JOSEPH LORING Signed
2043 2024-02-13 13:38 Anonymous (not verified) 94.188.207.226 mannys handyman services Limited Liability Company 3084 120th st cumming ia 50061 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-13 manuel v banegas mannyshandymanservices.ia@gmail.com cumming 3084 120th st iowa Adam Boge Lance Webster Signed (1) The employer does not elect the employers’ liability coverage. manuel v banegas mannyshandymanservices.ia@gmail.com self employeed Cumming Madison Iowa Adam Boge Lance Webster Signed
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
2079 2024-03-06 18:59 Anonymous (not verified) 94.188.205.166 Maple Leaf Landscape Maintenance Proprietorship 309 E. Exchange St Geneseo IL 61254 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-05 Chris Walters Mapleleaf@mapleleaflawnsolutions.com GENESEO IL United States Bobbi Jo Cox Victor Snook Signed (1) The employer does not elect the employers’ liability coverage. Chris Walters mapleleaf@mapleleaflawnsolutions.com Self GENESEO IL United States Bobbi Jo Cox Victor Snook Signed
1606 2023-04-26 11:42 Anonymous (not verified) 94.188.205.166 Dean Petty Proprietorship 309 Locust Street De Soto I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Dean Robert Petty dean.r.petty@gmail.com De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Dean Robert Petty dean.r.petty@gmail.com Owner 309 Locust Street De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed
1607 2023-04-26 11:42 Anonymous (not verified) 94.188.205.166 Dean Petty Proprietorship 309 Locust Street De Soto I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-26 Dean Robert Petty dean.r.petty@gmail.com De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed (1) The employer does not elect the employers’ liability coverage. Dean Robert Petty dean.r.petty@gmail.com Owner 309 Locust Street De Soto Dallas Iowa Sheanah Wright Derek Mullins Signed
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
1873 2023-10-20 09:25 Anonymous (not verified) 94.188.207.228 GC Hauling LLC Limited Liability Company 310 North 18th Street, Indianola, IA, 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-20 Garrett Joseph Claerhout gjclaerhout@hotmail.com INDIANOLA IA IA Kirsten Claerhout Jay Claerhout Signed (1) The employer does not elect the employers’ liability coverage. Garrett Joseph Claerhout gjclaerhout@hotmail.com Same Person INDIANOLA IA IA Kirsten Claerhout Jay Claerhout Signed
98 2020-03-23 15:07 Anonymous (not verified) 65.120.236.250 Cross Roads Logistics, LLC Limited Liability Company 3103 21st St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-23 Mark Alan Cross rcreek2016@gmail.com Davenport IA IA Lori Ann Cross Barbara A Deering Signed (1) The employer does not elect the employers’ liability coverage. Mark Alan Cross rcreek2016@gmail.com President/Owner Davenport IA IA Lori Ann Cross Barbara A Deering Signed
1681 2023-06-08 15:55 Anonymous (not verified) 94.188.207.223 Cross Roads Builders, LLC Limited Liability Company 3103 21st Street Camanche, IA.52730 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-08 Mark Allan Cross rcreek2016@gmail.com Davenport iowa United States Barb Deering Mike Cross Signed (1) The employer does not elect the employers’ liability coverage. Mark Cross rcreek2016@gmail.com Owner/President Davenport IA United States Barb Deering Mike Cross Signed
1824 2023-08-29 16:20 Anonymous (not verified) 94.188.205.176 Miller Construction Siding & Windows, LLC Limited Liability Company 3104 S.W. 26TH STREET, ANKENY, IA. 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-29 SCOTT MICHAEL DORAU SMD50021@GMAIL.COM Ankeny Polk United States Christopher Bohn Jeffrey Bohn Signed (1) The employer does not elect the employers’ liability coverage. SCOTT MICHAEL DORAU SMD50021@GMAIL.COM PRESIDENT Ankeny POLK United States CHRISTOPHER BOHN JEFFREY BOHN Signed
2205 2024-05-07 08:56 Anonymous (not verified) 94.188.207.227 MILLER CONSTRUCTION SIDING & WINDOWS, LLC Limited Liability Company 3104 SW 26TH STREET, ANKENY, IA. 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-07 SCOTT MICHAEL DORAU scott@millersidingandwindows.com ANKENY POLK IOWA ADAM BOGE LANCE WEBSTER Signed (1) The employer does not elect the employers’ liability coverage. SCOTT MICHAEL DORAU scott@millersidingandwindows.com OWNER ANKENY POLK IOWA ADAM BOGE LANCE WEBSTER Signed
2170 2024-04-22 10:11 Anonymous (not verified) 94.188.207.224 Joy Ride Transport Limited Liability Company 3105 SE Miehe Drive, Grimes, IA 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-22 Ted Cochran ted@ridejoyride.com Clive Dallas IA Lindsey Pace Carissa Gehrking Signed (1) The employer does not elect the employers’ liability coverage. Ted Cochran ted@ridejoyride.com Self Clive Dallas IA Lindsey Pace Carissa Gehrking Signed
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
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
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
1592 2023-04-22 22:46 Anonymous (not verified) 94.188.207.223 D&L painting LLC Limited Liability Company 3109 E13th st des moines IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-22 Lenin Borjas Varela leninborjas92@gmail.com Des moines Iowa Iowa Berenice Silva Gustado Valdes Signed (1) The employer does not elect the employers’ liability coverage. Lenin Borjas Varela leninborjas92@gmail.com Dueño Clive Iowa Iowa Berenice silva Gustado Valdes Signed
137 2020-04-28 10:08 Anonymous (not verified) 74.84.101.138 Nisse Preschool & Kids Place Partnership 311 College Drive Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-26 Megan Sherman chelsea.whalen@upperiowains.com Decorah Winneshiek IA Michelle Ostern Robin C Schultz Signed (1) The employer does not elect the employers’ liability coverage. Megan Sherman chelsea.whalen@upperiowains.com President Decorah Winneshiek IA Michelle Ostern Robin C Schultz Signed
138 2020-04-28 10:10 Anonymous (not verified) 74.84.101.138 Nisse Preschool & Kids Place Partnership 311 College Drive Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-26 Tasha Sibley chelsea.whalen@upperiowains.com Decorah Winneshiek IA Michelle Ostern Robin C Schultz Signed (1) The employer does not elect the employers’ liability coverage. Tasha Sibley chelsea.whalen@upperiowains.com Secretary Decorah Winneshiek IA Michelle Ostern Robin C Schultz Signed
139 2020-04-28 10:11 Anonymous (not verified) 74.84.101.138 Nisse Preschool & Kids Place Partnership 311 College Drive Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-26 Kathleen Schutte chelsea.whalen@upperiowains.com Decorah Winneshiek IA Michelle Ostern Robin C Schultz Signed (1) The employer does not elect the employers’ liability coverage. Kathleen Schutte chelsea.whalen@upperiowains.com Treasurer Decorah Winneshiek IA Michelle Ostern Robin C Schultz Signed
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
276 2020-10-08 12:55 Anonymous (not verified) 65.103.82.36 Ron Ray Limited Liability Company 311 N Division Creston Iowa 50801 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-08 Ron L Ray 641-782-0521@gmail.com Creston Union Iowa Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. Ron L Ray 641-782-0521@gmail.com Self Creston Union Iowa Kayla Artioli Eric Johnson Signed
386 2021-02-08 12:10 Anonymous (not verified) 192.30.185.142 CS Iron Design Proprietorship 311 Powells Addition, Crescent, IA 51526 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-08 Christopher Stoffel ctstoffel@gmail.com Crescent Pottawattamie IA Katie Jenks Nate Blaeser Signed (1) The employer does not elect the employers’ liability coverage. Christopher Stoffel ctstoffel@gmail.com Owner Crescent Pottawattamie IA Katie Jenks Nate Blaeser Signed
219 2020-07-31 08:49 Anonymous (not verified) 173.31.147.225 JOHN RUPP Proprietorship 3110 TYLER AVENUE HARTLEY IA 51346 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-30 JOHN P RUPP THEELECTRICIANLLC@OUTLOOK.COM HARTLEY OBRIEN IOWA TAMI KLEIN KRIS WALKER Signed (1) The employer does not elect the employers’ liability coverage. JOHN P RUPP THEELECTRICIANLLC@OUTLOOK.COM SELF HARTLEY OBRIEN IA TAMI KLEIN KRIS WALKER Signed
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
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
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
852 2022-01-21 15:52 Anonymous (not verified) 75.162.3.62 Alternative Interventions, LLC Limited Liability Company 3116 Ingersoll, #4 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-21 Carla Olson altint3116@gmail.com West Des Moines Dallas United States Michelle Grandstaff Alexandra Killinger Signed (1) The employer does not elect the employers’ liability coverage. CARLA OLSON altint3116@gmail.com Owner DES MOINES Polk United States Michelle Grandstaff Alexandra Killinger Signed
1397 2022-12-21 14:05 Anonymous (not verified) 50.81.162.60 Jesse Iseminger Proprietorship 3117 e 40th ct, Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-21 Jesse Iseminger Jesseiseminger@gmail.com Des Moines Polk Iowa Shelly Johns Brad Weikert Signed (1) The employer does not elect the employers’ liability coverage. Jesse Iseminger Jesseiseminger@gmail.com Self Des Moines Iowa Iowa Shelly Johns Brad Weikert Signed
1431 2023-01-25 16:24 Anonymous (not verified) 172.56.249.51 Warren transport Limited Liability Company 3124 titan trail Waterloo,iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-25 Lamarcaus Lunford universalvoyager1@gmail.com Elkhart IN Indiana Quinetta shead Eric fikes Signed (1) The employer does not elect the employers’ liability coverage. Lamarcaus Lunford universalvoyager1@gmail.com Owner Elkhart IN Indiana Quinetta shead Eric fikes Signed
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
194 2020-06-24 15:24 Anonymous (not verified) 173.16.140.254 Eugene Behle Proprietorship 3134 6th Ave Des Moines IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-24 Eugene Behle III Bub4bme@gmail.com Des Moines Polk Iowa Kelly Coluzzi Mitch Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Eugene Behle III Bub4bme@gmail.com Self Des Moines POLK Iowa Kelly Coluzzi Mitch Coluzzi Signed
335 2020-12-08 11:08 Anonymous (not verified) 173.18.16.129 quintanillas construction llc Limited Liability Company 3136 6th ave des moines ia 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-08 maynor quintanilla maynorquintanilla42@gmail.com des moines polk Iowa Lesa Reeves Jen Lambert Signed (1) The employer does not elect the employers’ liability coverage. maynor quintanilla maynorquintanilla42@gmail.com owner des moines polk Iowa Lesa Reeves Jen Lambert Signed
1364 2022-11-09 09:57 Anonymous (not verified) 50.80.120.38 Egl Enterprises, Inc. Proprietorship 314 2ND AVE NW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-09 EUGENE G LARUE egl.enterprises.inc@gmail.com HAMPTON IA United States stephanie hofer aryel laRue Signed (1) The employer does not elect the employers’ liability coverage. EUGENE G LARUE egl.enterprises.inc@gmail.com self HAMPTON IA United States stephanie hofer aryel laRue Signed
1184 2022-07-06 15:10 Anonymous (not verified) 149.20.238.108 Shelby County Fair Corporation Limited Liability Company 314 4th St. Harlan, IA 51537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Kaylee Goshorn shelbycountyfair@fmctc.com Harlan Shelby iowa Kate Heese Katie Petersen Signed (1) The employer does not elect the employers’ liability coverage. Kaylee Goshorn shelbycountyfair@fmctc.com Board Member Harlan Shelby Iowa Kate Heese Katie Petersen Signed
1185 2022-07-06 15:12 Anonymous (not verified) 149.20.238.108 Shelby County Fair Corporation Limited Liability Company 314 4th St. Harlan, IA 51537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Darren Goshorn shelbycountyfair@fmctc.com Harlan Shelby Iowa Kate Heese Katie Petersen Signed (1) The employer does not elect the employers’ liability coverage. Darren Goshorn shelbycountyfair@fmctc.com Board Member Harlan Shelby IA Kate Heese Katie Petersen Signed
1187 2022-07-06 15:51 Anonymous (not verified) 149.20.238.108 Shelby County Fair Corporation Limited Liability Company 314 4th St. Harlan, IA 51537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Kyle Manz shelbycountyfair@fmctc.com Harlan Shelby Iowa Kate Heese Katie Petersen Signed (1) The employer does not elect the employers’ liability coverage. Kyle Manz shelbycountyfair@fmctc.com Board Member Harlan Shelby Iowa Kate Heese Katie Petersen Signed
1186 2022-07-06 15:49 Anonymous (not verified) 149.20.238.108 Shelby County Fair Corporation Limited Liability Company 314 4th St., Harlan, IA 51537 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-06 Lee Schoof shelbycountyfair@fmctc.com Harlan Shelby Iowa Kate Heese Katie Petersen Signed (1) The employer does not elect the employers’ liability coverage. Lee Schoof shelbycountyfair@fmctc.com Board Member harlan Shelby Iowa Kate Heese Katie Petersen Signed
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
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
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
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
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
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
1556 2023-04-05 14:08 Anonymous (not verified) 94.188.205.169 Capstone Staffing Solutions LLC Limited Liability Company 315 E 5th St, STE 202, Waterloo, IA, 50703 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-05 Peterson Munyasia pete@capstonestaffingsolutions.com Allen USA TX Daniel Mwangi Elizabeth Munene Signed (1) The employer does not elect the employers’ liability coverage. Peterson Munyasia pete@capstonestaffingsolutions.com Owner Allen USA TX Daniel Mwangi Elizabeth Munene Signed
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
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
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
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
546 2021-06-22 15:41 Anonymous (not verified) 208.95.1.97 BAJ FLOORING, LLC Limited Liability Company 31533 CASTLE COURT, DYERSVILLE, IA. 52040 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-06-11 BRIAN JACQUE jacquebrian18@gmail.com DYERSVIILLE DUBUQUE IOWA STEPHEN J. SCHLUETER PAULA FITZGERALD Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. BRIAN JACQUE jacquebrian18@gmail.com LLC MEMBER DYSERSVILLE DUBUQUE IOWA STEPHEN J. SCHLUETER PAULA FITZGERALD Signed
633 2021-09-08 10:35 Anonymous (not verified) 208.95.1.97 BAJ Flooring, LLC Limited Liability Company 31533 Castle Ct. Dyersville, IA. 52040-7600 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2021-09-08 Brian Jacque JacqueBrian18@gmail.com Dyersville Dubuque Iowa Stephen J. Schluter Paula Fitzgerald Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Brian A. Jacque JacqueBrian18@gmail.com LLC MEMBER Dyersville DUBUQUE IOWA Stephen J. Schlueter Stephen J. Schlueter Signed
1120 2022-05-19 09:49 Anonymous (not verified) 65.125.92.130 JG Landscaping, LLC Limited Liability Company 317 E 23rd St. Des Moines, IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-19 Javier Alexander Guzman alexguz76@outlook.com Des Moines Polk IA Brenda Reedy Chad Smith Signed (1) The employer does not elect the employers’ liability coverage. Javier Alexander Guzman alexguz76@outlook.com Self Des Moines Polk IA Brenda Reedy Chad Smith Signed
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
765 2021-11-22 16:07 Anonymous (not verified) 63.229.189.35 Stahmer Construction Proprietorship 318 Jackson St N Harris IA 51345 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Alan Stahmer abigail@rickmilesartisans.com Harris Osceola Iowa Abigail Miles Alex Miles Signed (1) The employer does not elect the employers’ liability coverage. Alan Stahmer abigail@rickmilesartisans.com Self Harris Osceola Iowa Abigail Miles Alex Miles Signed
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
1219 2022-07-21 12:39 Anonymous (not verified) 98.22.2.115 Keeling Services Proprietorship 3190 SE 64th St, pleasant Hill, IA 50327 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-21 Josh keeling Joshuakeeling110@gmail.com Pleasant Hill Iowa United States Kali Keeling Matthew Keeling Signed (1) The employer does not elect the employers’ liability coverage. Mark Bond mbond@leaffilter.com Regional sales manager Grimes Polk Iowa Kali Keeling Matthew Keeling Signed
118 2020-04-13 11:48 Anonymous (not verified) 173.26.152.222 Society of St. Vincent de Paul, District Council of Waterloo Iowa,Inc Limited Liability Company 320 Broadway St PO Box 2727 Waterloo IA 50704 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-14 Joseph D. Sobczyk joczyk@aol.com Cedar Falls Black Hawk Iowa George W. Karnick Glynis R. Worthington Signed (1) The employer does not elect the employers’ liability coverage. Joseph D. Sobczyk joczyk@aol.com self Cedar Falls Black Hawk Iowa George W. Karnick Glynis R. Worthington Signed
121 2020-04-14 15:11 Anonymous (not verified) 173.31.176.75 Society of St. Vincent de Paul, District council of Waterloo Iowa,Inc Limited Liability Company 320 Broadway St PO Box 2727 Waterloo IA 50704 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-14 Michele E Collison darmstad48@aol.com Denver Bremer Iowa George W. Karnick Glynis R. Worthington Signed (1) The employer does not elect the employers’ liability coverage. Joseph D. Sobczyk joczyk@aol.com Secretary of the St. Vincent de Paul District Council of Waterloo, Iowa, Inc. Denver Bremer Iowa George W. Karnick Glynis R. Worthington Signed
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
2192 2024-04-29 13:15 Anonymous (not verified) 94.188.205.166 ElmStreet Apothecary Limited Liability Company 320 W Kimberly Road #227 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-29 Erica McGee esalsbury07@gmail.com Bettendorf Scott Ia Jennifer West Julie Francis Signed (1) The employer does not elect the employers’ liability coverage. Erica McGee esalsbury07@gmail.com Self Bettendorf Scott Ia Jennifer West Julie Francis Signed
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
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
2156 2024-04-16 17:00 Anonymous (not verified) 94.188.205.166 BONILLA STONE LLC Limited Liability Company 3201 COLUMBIA ST DES MOINES, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-16 JAIRO JAVIER BONILLA SERRANO jairobonilla509@gmail.com DES MOINES POLK IOWA ROCIO REYES JOSE HERNANDEZ Signed (1) The employer does not elect the employers’ liability coverage. JAIRO JAVIER BONILLA SERRANO jairobonilla509@gmail.com SAME DES MOINES POLK IOWA ROCIO REYES JOSE HERNANDEZ Signed
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
967 2022-03-11 13:41 Anonymous (not verified) 205.221.255.62 Bard Inspection Services LLC Limited Liability Company 3207 W Van Buren Ave, Fairfield, IA 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-11 Stephanie Bard bardfamily4@gmail.com Fairfield Jefferson IA Miranda Millhouse Justin Millhouse Signed (1) The employer does not elect the employers’ liability coverage. Stephanie Bard bard.inspections@gmail.com owner Fairfield Jefferson IA Miranda Millhouse Justin Millhouse Signed
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
679 2021-10-18 13:14 Anonymous (not verified) 173.18.22.217 Xscape Extreme Hard & Landscape Proprietorship 3215 E 25th CT Bldg Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-18 Mike Tapper Tapper4981@gmail.com Des Moines Polk IA Lesa Dillon Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Michael Tapp Tapper4981@gmail.com Owner Des Moines Des Moines IA Lesa Dillon Kelly Coluzzi Signed
1118 2022-05-18 11:12 Anonymous (not verified) 174.215.249.55 Nilson construction Proprietorship 3219 bowdoin st Des Moines Iowa 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-18 Romel Edenilson saravia Aparicio romelsaravia5@gmail.com Des Moines Polk Iowa Alvaro camacho Ricardo Iyan campuzano Signed (1) The employer does not elect the employers’ liability coverage. Romel edenilson saravia aparicio romelsaravia5@gmail.com Employer Des Moines Polk Iowa Alvaro camacho Ricardo iyan campuzano Signed
777 2021-12-04 10:20 Anonymous (not verified) 107.77.161.58 Martinez Painting Proprietorship 3219 bowdoin st desmoines ia 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-04 Martinez Manuel Manuelitogladis29@gmail.com Desmoines Polk Iowa Yasco adilovic Samir radinovick Signed (1) The employer does not elect the employers’ liability coverage. Martinez Manuel Manuelitogladis29@gmail.com Owner Desmoines Polk Iowa Yasco adilovic Samir radinovic Signed
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
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
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
1875 2023-10-23 11:34 Anonymous (not verified) 94.188.205.176 Makers Blinds LLC Limited Liability Company 3220 44Th St Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-23 Ryan Seiler makersblinds@gmail.com Des Moines Polk Iowa Jon Buller Terry Miles Signed (1) The employer does not elect the employers’ liability coverage. Ryan Seiler makersblinds@gmail.com Manager Des Moines Polk Iowa Jon Buller Terry Miles Signed
1851 2023-09-22 12:36 Anonymous (not verified) 94.188.207.229 MNM Construction Proprietorship 3224 sw 12th place des moines iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-22 craig allen mccormick craigmccormick.6363@gmail.com Des Moines Iowa Iowa Tara Murphy Kristie Hubbard Signed (1) The employer does not elect the employers’ liability coverage. craig mccormick craigmccormick.6363@gmail.com self Des Moines Iowa Iowa Tara Murphy Kristie Hubbard Signed
300 2020-10-30 10:51 Anonymous (not verified) 216.51.132.207 Joe Kann & Luke Kann Partnership 32256 Leaf Rd Guttenberg IA 52052 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-28 Joe Kann kannbros1895@gmail.com Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Joe Kann kannbros1895@gmail.com owner Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
301 2020-10-30 10:53 Anonymous (not verified) 216.51.132.207 Joe Kann & Luke Kann Partnership 32256 Leaf Rd Guttenberg IA 52052 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-27 Luke Kann kannbros1895@gmail.com Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed (1) The employer does not elect the employers’ liability coverage. Luke Kann kannbros1895@gmail.com owner Guttenberg Clayton Iowa Jerry J Rochford Nicole L Parker Signed
1809 2023-08-21 07:55 Anonymous (not verified) 94.188.207.228 Gonzalez Drywall LLC Limited Liability Company 323 Friendhip St Apt 3, Iowa City, IA 52245 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-21 Leonel Angel Gonzalez victorangel8373@gmail.com Iowa City Johnson Iowa Chris Hay Brad Bower Signed (1) The employer does not elect the employers’ liability coverage. Leonel Angel Gonzalez victorangel8373@gmail.com Self Iowa City Johnson Iowa Chris Hay Brad Bower Signed
1739 2023-07-11 12:18 Anonymous (not verified) 94.188.205.169 Innovators Construction LLC Limited Liability Company 3230 180th St. Homestead, IA 52236. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Juan Ramírez info@jmdrywallonline.com Homestead Iowa Iowa Itali Ramírez Guadalupe Ramirez Signed (1) The employer does not elect the employers’ liability coverage. Guadalupe Ramirez info@jmdrywallonline.com Business partner Homestead Iowa Iowa Itali Ramírez Juan M Ramírez Signed
1647 2023-05-15 14:11 Anonymous (not verified) 94.188.207.227 Innovators construction llc Limited Liability Company 3234 180th St. Homestead, IA 52236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-15 Guadalupe Ramirez info@jmdrywallonline.com Homestead Iowa Iowa Itali Ramírez Manuela Muñoz Signed (1) The employer does not elect the employers’ liability coverage. Juan M Ramírez info@jmdrywallonline.com Owner/spouse Homestead Iowa Iowa Itali Ramírez Manuela Muñoz Signed
1740 2023-07-11 12:22 Anonymous (not verified) 94.188.205.168 Innovators Construction LLC Limited Liability Company 3234 180th St., Homestead, IA 52236 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-11 Guadalupe Ramirez imfo@jmdrywallonline.com Homestead Iowa Iowa Itali Ramírez Juan m Ramírez Signed (1) The employer does not elect the employers’ liability coverage. Juan M Ramírez info@jmdrywallonline.com Business partner Homestead Iowa Iowa Itali Ramírez Juan m Ramírez Signed
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
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
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
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
220 2020-08-02 13:45 Anonymous (not verified) 99.203.112.113 R&G SEAMLESS GUTTERS Proprietorship 3244 Dubuque Ave, 3244 Dubuque Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-02 Ruben Munoz Haro munozharoruben@gmail.com Des Moines Polk Estados Unidos Gabriel Ramirez Adriana Ramirez Signed (1) The employer does not elect the employers’ liability coverage. Ruben Munoz- R&G SEAMLESS GUTTERS Munozharoruben@gmail.com owner 3244 Dubuque Ave Des Moines Iowa 50317 polk iowa Gabriel Ramirez Adriana Ramirez Signed
1446 2023-02-08 16:49 Anonymous (not verified) 94.188.207.228 ZAHID ALI Limited Liability Company 3245 SOUTHGATE PL SW, IOWA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-10 ZAHID ALI ali@americaninncid.com CEDAR RAPIDS USA IOWA ZAHID ALI ZAHID ALI Signed (1) The employer does not elect the employers’ liability coverage. ZAHID ALI ali@americaninncid.com self cedar rapids usa iowa ZAHID ALI ZAHID ALI Signed
1200 2022-07-11 19:24 Anonymous (not verified) 208.126.69.118 CMG Safety Limited Liability Company 325 1st st. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 Chace Michael Garner chgarner18@gmail.com Truro Madison Iowa Josh Tomkins Kirsten Schirm Signed (1) The employer does not elect the employers’ liability coverage. Josh Tompkins josh.thomkins@307safety.com Contractor Gillette Cambell Wyoming Chace Garner Kirsten Schirm Signed
1655 2023-05-19 14:19 Anonymous (not verified) 94.188.207.229 Cutting Edge Concrete LLC Limited Liability Company 325 Linn St, Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-19 Joel Waltz joel@cuttingedgeiowa.com Boone Boone Iowa Robert Simmons Deb Ernst Signed (1) The employer does not elect the employers’ liability coverage. Joel Waltz joel@cuttingedgeiowa.com Self Boone Boone IA Robert Simmons Deb Ernst Signed
101 2020-03-24 15:49 Anonymous (not verified) 161.69.123.10 Blair Lincoln Proprietorship 32586 390th St Colesburg, IA 52035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-24 Blair Alan Lincoln balincoln@gmail.com Colesburg County Iowa Brandon Mather Travis Ries Signed (1) The employer does not elect the employers’ liability coverage. Blair Alan Lincoln balincoln@gmail.com Owner Colesburg County IA Brandon Mather Travis Ries Signed
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
328 2020-11-26 12:28 Anonymous (not verified) 174.198.82.38 Duke millwright doing business as duke & sons Limited Liability Company 3264 e Payton ave Des Moines iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2020-11-26 Jeremiah duke jpduke24.7.365@gmail.com Des Moines Polk county Iowa Daniel Patrick Hemann Nikki Marie Harvey Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Diana duke dukemillwright@gmail.com Self Des Moines Polk Iowa Nikki Marie Harvey Daniel Patrick Hemann Signed
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
1016 2022-03-29 14:26 Anonymous (not verified) 104.145.202.155 S.M.Trucking Proprietorship 3270 Hwy 69 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-29 Steve Miller S.M.Trucking52@gmail.com 3270 Hwy 69 Forest City Hancock Ia Julie Miller Amy Picha Signed (1) The employer does not elect the employers’ liability coverage. Steve Miller S.M.Trucking52@gmail.com Owner 3270 Hwy 69 Forest City Hancock Ia Julie Miller Amy Picha Signed
1705 2023-06-23 16:01 Anonymous (not verified) 94.188.205.176 MV Carpentry LLC Limited Liability Partnership 32724 U.S. 69 Huxley IA 50124 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-23 Carlos Moreno Silencitopunk@gmail.com Huxley IA United States Alejandro Colin Fermin Luz Signed (1) The employer does not elect the employers’ liability coverage. Carlos Moreno silencitopunk@gmail.com Husband Huxley IA United States Alejandro Colin Fermin Luz Signed
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
913 2022-02-14 18:50 Anonymous (not verified) 72.25.23.147 Teimer Trucking Limited Liability Company 3277 102nd St. Durant, IA 52747 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-14 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Cedar Iowa Barry Boll Jennifer Treimer Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Owner Tipton Cedar Iowa Barry Boll Jennifer Treimer Signed
1803 2023-08-15 19:03 Anonymous (not verified) 94.188.207.224 Teimer Trucking LLC Limited Liability Company 3277 102nd St. Durant, IA 52747-9524 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-15 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Iowa United States Spencer Lea Parsons Sydney Rae Lane Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Self Tipton Iowa United States Spencer Lea Parsons Sydney Rae Lane Signed
1808 2023-08-17 17:17 Anonymous (not verified) 94.188.205.168 Treimer Trucking LLC Limited Liability Company 3277 102nd St. Durant, IA 52747-9524 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-17 Daniel Dennis Treimer dtreimer65@gmail.com Tipton Iowa United States Sydney Rae Lane Spencer Lea Parsons Signed (1) The employer does not elect the employers’ liability coverage. Daniel Dennis Treimer dtreimer65@gmail.com Self Tipton Iowa United States Syndey Rae Lane Spencer Lea Parsons Signed
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
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
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
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
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
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
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
743 2021-11-11 15:19 Anonymous (not verified) 72.13.16.172 ROLING TRANSPORT LLC Limited Liability Company 33041 395TH AVENUE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 ROLING TRUCKING LLC dave@allseasonstrucking.com BELLEVUE JACKSON IA Dave Neuwohner BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. ROLING TRUCKING LLC dave@allseasonstrucking.com PRESIDENT BELLEVUE JACKSON IA Dave Neuwohner BEN MOYER Signed
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
979 2022-03-15 13:48 Anonymous (not verified) 72.255.78.146 Custom Climates Partnership 3305 Highway 1 SW Ste 9A Iowa City IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-15 Allen Nichols ranichols4@gmail.com CEDAR RAPIDS Iowa IA Rose Nichols Rose Nichols Signed (1) The employer does not elect the employers’ liability coverage. Allen Nichols ranichols4@gmail.com spouse CEDAR RAPIDS Iowa IA Rose Nichols Rose Nichols Signed
672 2021-10-13 16:05 Anonymous (not verified) 75.162.218.218 Arturos Interiors LLC Limited Liability Company 3305 se 22nd apt 15 Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-29 Arturo mejia arturomcruz20@hotmail.com Des Moines polk IA yolanda mendoza liliana sanchez Signed (1) The employer does not elect the employers’ liability coverage. Arturo Mejia arturomcruz20@hotmail.com member Des Moines polk IA Yolanda Mendoza lialiana sanchez Signed
393 2021-02-11 12:36 Anonymous (not verified) 173.21.130.224 Ashby Roofing Proprietorship 3307 Clearwater dr Bettendorf I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-11 Thomas Ashby Tashby8@aol.com Bettendorf Scott Iowa Veronica Ashby Tommy Ashby Signed (1) The employer does not elect the employers’ liability coverage. United Insurance Counslers Tashby8@aol.com owner Bettendorf Scott Iowa Veronica Ashby Tommy Ashby Signed
2136 2024-04-04 16:08 Anonymous (not verified) 94.188.205.169 Elite Construction & Masonry LLC Limited Liability Company 3309 Wright St Des Moines IA 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-04 Manuel Mejia eliteconstructionmasonryllc@gmail.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Manuel Mejia eliteconstructionmasonryllc@gmail.com Self Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
2107 2024-03-19 12:33 Anonymous (not verified) 94.188.205.175 Elit Construction and Masonry LLC Partnership 3309 Wright St. Des Moines, Ia 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-19 Manuel Mejia elitconstructionmasonryllc@gmail.com Des Moines Polk Iowa Heather Garber Kyle Johnson Signed (1) The employer does not elect the employers’ liability coverage. Manuel Mejia elitconstructionmasonryllc@gmail.com self Des Moines Polk Iowa Heather Garber Kyle Johnson Signed
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
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
1891 2023-11-02 06:24 Anonymous (not verified) 94.188.207.225 DOC Services Proprietorship 3313 , E 7th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-01 Quentin Ferguson 1quensy@gmail.com Des Moines Polk IA Dione Fergsuon Quensy Ferguson Signed (1) The employer does not elect the employers’ liability coverage. Quentin Ferguson 1quensy@gmail.com Self Des Moines Polk Ia Dione Ferguson Quensy Ferguson Signed
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
78 2020-02-25 09:35 Anonymous (not verified) 65.127.131.118 Rey Construction, LLC Proprietorship 3317 Scott Ave Des Moines, iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-02 Juan Raymundo Hernandez reyano43@gmail.com Des Moines polk iowa Rigoberto Mayorga Y Bounv Quang Signed (1) The employer does not elect the employers’ liability coverage. Preferred Interior Construction INC dba PIC INC deb@piciowa.com PIC, INC-contractor, Rey Construction, LLC-subcontractor Altoona IA United States Martin Pinon Evan Bianchi Signed
2194 2024-04-30 14:57 Anonymous (not verified) 94.188.207.223 Juan Raymundo Hernandez Proprietorship 3317 Scott Ave Des Moines, Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-25 Juan Raymundo Hernandez deb@piciowa.com Des Moines Poik Iowa Kelly Denger Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. Juan Raymundo Hernandez deb@piciowa.com self Des Moines Polk Iowa Kelly Denger Debra Stratton Signed
959 2022-03-09 10:30 Anonymous (not verified) 207.199.231.172 Steve Shepherd Proprietorship 332 N Walnut St Fremont, IA 52561 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-09 Steve Shepherd sheps2s69@gmail.com Fremont Mahaska Iowa James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Steve Shepherd sheps2s69@gmail.com Self Fremont Mahaska Iowa James Anderson Ashley Bryan Signed
457 2021-04-04 17:35 Anonymous (not verified) 104.237.118.236 Lundt Transport, LLC Limited Liability Company 3322 Y AVE. FAIRBANK, IA 50629 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-04 SAMUEL LUNDT samuelrl1998@gmail.com FAIRBANK Iowa Iowa CYNTHIA LUNDT KATLYN HILL Signed (1) The employer does not elect the employers’ liability coverage. SAMUEL LUNDT samuelrl1998@gmail.com SELF FAIRBANK FAYETTE Iowa CYNTHIA LUNDT KATLYN HILL Signed
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
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
1462 2023-02-17 13:45 Anonymous (not verified) 94.188.207.227 Med Spa Institute of America, Dubuque LLC Limited Liability Partnership 3337 Hillcrest Rd - Dubuque, IA 52002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-11 Kaylee Webb jheims@english-insurance.com Dubuque Dubuque United States Joyce Heims Derrick Parsons Signed (1) The employer does not elect the employers’ liability coverage. Joyce Heims jheims@english-insurance.com self Dyersville IA United States Joyce Heims Derrick Parsons Signed
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
1721 2023-07-06 08:19 Anonymous (not verified) 94.188.207.228 Bradford Alexander Carr Proprietorship 3349 Southgate Ct SW Ste 101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-06 Bradford Alexander Carr alex.carr@thrivent.com Coralville Johnson Iowa Gaylon Heetland David King Signed (1) The employer does not elect the employers’ liability coverage. Bradford Alexander Carr alex.carr@thrivent.com Self Coralville Johnson Iowa Gaylon Heetland David King Signed
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
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
856 2022-01-26 13:44 Anonymous (not verified) 69.63.16.2 Rick Peterson Proprietorship 3366 Lynden Heights Rd NE, Iowa City IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-26 Richard Peterson insurancecommercialsam@greenstate.org Iowa City Johnson Iowa Jonathan Gonzalez Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Rick Peterson insurancecommercialsam@greenstate.org Owner Iowa City Johnson IA Jonathan Gonzalez Dyan Kriener Signed
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
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
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
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
144 2020-04-29 11:20 Anonymous (not verified) 65.158.103.107 Symbiotic Gardens LLC Limited Liability Company 3403 Dubuque Avenue Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-29 Brandon Kam symbioticgardens@gmail.com Des Moines Polk Iowa Kathy Schulte Larry Johnson Signed (1) The employer does not elect the employers’ liability coverage. Brandon Kam symbioticgardens@gmail.com same Des Moines Polk Iowa Kathy Schulte Larry Johnson Signed
1140 2022-06-02 21:20 Anonymous (not verified) 167.142.38.107 BV Transport LLC Limited Liability Company 3406 150th Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-02 Brody Joseph Vaske Brody.vaske44@gmail.com Bancroft IA United States Ed Goche Kelly Deitering Signed (1) The employer does not elect the employers’ liability coverage. Brody Vaske Brody.vaske44@gmail.com Self Bancroft IA United States Ed Goche Kelly Deitering Signed
1202 2022-07-11 21:14 Anonymous (not verified) 173.17.252.144 B SQUARED CONSTRUCTION Limited Liability Company 3407 skyline drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-11 MARC BROOKER BSquared066@gmail.com Des Moines United states IA marc brooker MARC BROOKER Signed (1) The employer does not elect the employers’ liability coverage. MARC BROOKER BSquared066@gmail.com owner Des Moines IA IA MARC BROOKER MARC BROOKER Signed
917 2022-02-16 09:48 Anonymous (not verified) 167.142.86.212 Susan A Cunningham Proprietorship 3409 Stone City Rd, Central City IA 52214 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-16 Susan A Cunningham 2oldrabbits@gmail.com Central City Linn Iowa Donna Zimmerman Norm Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Susan A Cunningham 2oldrabbits@gmail.com self Central City Linn Iowa Donna Zimmerman Norm Zimmerman Signed
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
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
1208 2022-07-15 11:06 Anonymous (not verified) 173.18.22.217 JL Elite Painting Limited Liability Company 3416 NW 20th St Ankeny IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-15 Lizeth Benitez jl.elite.painting@gmail.com Ankeny Polk IA Lesa Reeves Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Lizeth Benitez jl.elite.painting@gmail.com owner Ankeny Polk IA Lesa Reeves Kelly Coluzzi Signed
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
2026 2024-02-07 08:32 Anonymous (not verified) 94.188.205.169 Strong Fencing & Decking LLC Limited Liability Company 343 59th Street Des Moines Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 Jacob James Strong strongfencingdecking@gmail.com Des Moines Polk Iowa Paige Crowley Jacob Waugh Signed (1) The employer does not elect the employers’ liability coverage. Jacob Strong strongfencingdecking@gmail.com Owner Des Moines Polk Iowa Paige Crowley Jacob Waugh Signed
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
2083 2024-03-08 14:41 Anonymous (not verified) 94.188.205.169 Michael Dwayne Wahl Jr DBA Dents Etc Proprietorship 3458 Highway 65/69, Carlisle, Iowa 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-08 Michael Dwayne Wahl Jr darrin@fisherbodypaint.com Carlisle Polk Iowa Darrin Morrison Anthony Garcia Signed (1) The employer does not elect the employers’ liability coverage. Mark Schreck mark.schreck@insurancestationinc.com Agent Altoona IA IA Darrin Morrison Anthony Garcia Signed
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
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
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
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
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
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
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
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
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
1714 2023-06-27 09:14 Anonymous (not verified) 94.188.205.167 Meier Trucking LLC Limited Liability Company 35032 308th St, Bellevue, IA 52031 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-14 Brandon Meier meierturcking87@yahoo.com Bellevue Jackson Iowa Susan Miller Nicole Mensen Signed (1) The employer does not elect the employers’ liability coverage. Brandon Meier meiertrucking87@yahoo.com self Bellevue Jackson Iowa Susan Miller Nicole Mensen Signed
147 2020-05-02 09:07 Anonymous (not verified) 75.162.65.142 Tim Soy Proprietorship 3506 Amherst Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-01 Timothy Soy kingsoyboy@hotmail.com Des Moines Polk Iowa Aaron Page Jeremy Lukehart Signed (1) The employer does not elect the employers’ liability coverage. Timothy Soy kingsoyboy@hotmail.com Self Des Moines Polk Iowa Aaron page Jeremy Lukehart Signed
317 2020-11-15 19:20 Anonymous (not verified) 172.58.83.192 All Cut Lawn Care Proprietorship 3506 Glover Ave. Des Moines Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-15 Michael D Money michaelmoney883@gmail.com Des Moines Polk Iowa Deanna L Phagan Diana J Jennings Signed (1) The employer does not elect the employers’ liability coverage. Michael D Money michaelmoney883@gmail.com Myself Des Moines Polk Iowa Deanna L Phagan Diana J Jennings Signed
809 2021-12-21 14:42 Anonymous (not verified) 75.162.173.166 Mike Money Proprietorship 3506 Glover Ave. Des Moines, Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-21 Michael David Money poojennings78@gmail.com Des Moines Polk Iowa Diana Jennings Steve Jennings Signed (1) The employer does not elect the employers’ liability coverage. Michael David Money poojennings78@gmail.com self Des Moines Polk Iowa Diana Jennings Steve Jennings Signed
7 2019-11-15 12:26 Anonymous (not verified) 173.17.129.166 Thomas C. Davis Proprietorship 3509 Franklin Ave, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-15 Thomas C. Davis III thomas.davis.iii@gmail.com Des Moines Polk Iowa Jared Vincent Kevin Corn Signed (1) The employer does not elect the employers’ liability coverage. Thomas C. Davis III thomas.davis.iii@gmail.com Employer Des Moines Polk Iowa Jared Vincent Kevin Corn Signed
313 2020-11-11 20:35 Anonymous (not verified) 174.198.78.148 Wilson Snow Maintenance Proprietorship 3518 183rd Avenue, Carlisle, Iowa 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-11 Bruce E. Wilson bewilson83@gmail.com Carlisle Warren Iowa Kristen Wilson Garett Wilson Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Bruce Wilson bewilson83@gmail.com self Carlisle Warren Iowa Kristen Wilson Garett Wilson Signed
1532 2023-03-24 18:05 Anonymous (not verified) 94.188.205.174 Crafty Dome LLC Limited Liability Company 3524 Stonebridge Rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-24 Susan Bernau craftydome@yahoo.com West Des Moines Polk Iowa George Cummins Linda Green Signed (1) The employer does not elect the employers’ liability coverage. Susan Bernau craftydome@yahoo.com owner 3524 Stonebridge Rd Polk Iowa George Cummins Linda Green Signed
1241 2022-08-03 10:56 Anonymous (not verified) 72.169.80.108 Landon Henriksen Proprietorship 35374 GARDEN AVE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-03 LANDON HENRIKSEN HENRIKSENLK@AOL.COM Edgewood IA United States LANDON HENRIKSEN LANDON HENRIKSEN Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. LANDON HENRIKSEN HENRIKSENLK@AOL.COM Same Edgewood IA United States Scott Johnson Josh lafond Signed
664 2021-10-05 15:01 Anonymous (not verified) 174.242.226.8 New Face Renovations Limited Liability Company 3563 Richland Circle Van Meter, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-05 Darin Benjamin Davis newfacereno@gmail.com Van Meter Dallas Iowa Ryan Young Betsy Davis Signed (1) The employer does not elect the employers’ liability coverage. Renda Building megemo@commdatalink.com Installer Grimes Polk Iowa Ryan Young Betsy Davis Signed
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
1830 2023-09-08 11:45 Anonymous (not verified) 94.188.205.177 Bradley A Sneeden Proprietorship 36 Sunset Drive, Beardstown, IL 62618 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-08 Bradley A Sneeden bradsneeden@gmail.com Beardstown Cass IL Billie Sneeden Dillon McNeff Signed (1) The employer does not elect the employers’ liability coverage. Bradley A Sneeden bradsneeden@gmail.com Self Beardstown Cass IL Billie Sneeden Dillon McNeff Signed
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
1287 2022-08-30 13:11 Anonymous (not verified) 173.18.22.217 Gomez Painting Limited Liability Company 3609 56th St Des Moines IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-30 Orlyn Gomez orlyngomez9@gmail.com Des Moines Polk Iowa Lesa Reeves Jen Lambert Signed (1) The employer does not elect the employers’ liability coverage. Orlyn Gomez orlyngomez9@gmail.com Owner Des Moines Polk Iowa Lesa Reeves Jen Lambert Signed
1402 2022-12-28 16:35 Anonymous (not verified) 208.69.145.91 DeRonde Flooring Inc. Proprietorship 3612 NW 178th Ct, Clive IA 50325 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-28 Brian DeRonde derondeflooring@gmail.com Clive Dallas IA Brian DeRonde Courtney DeRonde Signed (1) The employer does not elect the employers’ liability coverage. Brian DeRonde derondeflooring@gmail.com Self Clive Dallas IA Brian DeRonde Courtney DeRonde Signed
1009 2022-03-28 07:24 Anonymous (not verified) 173.18.6.21 Clay Windelmann Limited Liability Company 362 Public Square, Greenfield, IA 50849 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-28 C;ay Winkelman crwwproperties@gmail.com Fontanelle Adair Iowa Kathryn Larson Jacob Tiernan Signed (1) The employer does not elect the employers’ liability coverage. Clay Winkelmann crwwproperties@gmail.com Owner/Self Fontanelle Adair Iowa Kathryn Larson Jacob Tiernanq Signed
1555 2023-04-05 08:03 Anonymous (not verified) 94.188.207.227 DK Motor Freight Proprietorship 3621 Tyler Avenue I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-05 David Kirchner dkirchner89@gmail.com Hartley Obrien Iowa Janna VanDonge Chad Driesen Signed (1) The employer does not elect the employers’ liability coverage. David Kirchner dkirchner89@gmail.com Self Hartley Iowa United States Janna VanDonge Chad Driesen Signed
1550 2023-03-31 13:35 Anonymous (not verified) 94.188.205.177 Nadarevic Group LLC Limited Liability Company 3633 NW 177th Ct, Clive, IA 50325 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-31 Ajdin Nadarevic ajdin@silverstonedevgroup.com Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed (1) The employer does not elect the employers’ liability coverage. Ajdin Nadarevic ajdin@silverstonedevgroup.com Owner Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed
1551 2023-03-31 13:37 Anonymous (not verified) 94.188.205.176 Nadarevic Group LLC Limited Liability Company 3633 NW 177th Ct, Clive, IA 50325 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-31 Nicole Nadarevic niki@silverstonedevgroup.com Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed (1) The employer does not elect the employers’ liability coverage. Ajdin Nadarevic ajdin@silverstonedevgroup.com Owner Clive Dallas Iowa Jeremy Boysen Brooke Boysen Signed
201 2020-07-09 11:07 Anonymous (not verified) 167.142.98.40 Brock Chisum Proprietorship 369 Wise Rd., Decatur, TX76234 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-09 Brock Chisum bchisum@hotmail.com Decatur, TX Wise Texas Lakota Larson Ryan Stott Signed (1) The employer does not elect the employers’ liability coverage. Brock Chisum bchisum@hotmail.com Self Decatur Wise Texas Lakota Larson Ryan Stott Signed
2109 2024-03-21 11:15 Anonymous (not verified) 94.188.205.169 Panameno Stone Proprietorship 3701 SE 18th Ct. Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-21 Domingo Panameno albertpana08@gmail.com Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed (1) The employer does not elect the employers’ liability coverage. Domingo Panameno albertpana08@gmail.com Self Des Moines Polk Iowa Drakkar Rapaich Fabi Palomares Signed
815 2021-12-28 12:29 Anonymous (not verified) 173.29.239.122 Comtek, Inc. Proprietorship 3702 NW 13th St. Ankeny, Iowa 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-28 Micheal D. Qualley mqcomtek@gmail.com ANKENY IA United States Jacque Blackman Jeffery Keipper Signed (1) The employer does not elect the employers’ liability coverage. Jacque Blackman jblackman@grimesfinancialgroup.com client Grimes Polk Iowa Jacque Blackman Jeffery Keipper Signed
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
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
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
2002 2024-01-26 17:00 Anonymous (not verified) 94.188.207.228 Legacy Group Consulting Limited Liability Company 3721 Coppermill Rd NE, Cedar Rapids, IA 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-26 John A Scott legacygrpconsulting@gmail.com Cedar Rapids Linn IA Barbara Scott Robert Moore Signed (1) The employer does not elect the employers’ liability coverage. John A Scott legacygrpconsulting@gmail.com Owner Cedar Rapids Linn IA Barbara Scott Robert Moore Signed
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
1862 2023-10-05 14:30 Anonymous (not verified) 94.188.207.225 J trinidad Garcia Ferrer Proprietorship 3722 SE 14th St Apt 9 Des Moines, Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-01 J Trinidad Garcia Ferrer deb@piciowa.com Des Moines Polk Iowa Deb Stratton Martin Pinon Signed (1) The employer does not elect the employers’ liability coverage. J trinidad Garcia Ferrer deb@piciowa.com self Des Moines Polk IOwa Deb Stratton Martin Pinon Signed
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
429 2021-03-10 12:52 Anonymous (not verified) 173.23.50.65 Raleigh Electrical Services Limited Liability Company 3747 SE 10th St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-10 Timothy Bruce Raleigh tim@raleighelectrical.org Des Moines Polk Iowa Joe Coughlon Genna Prine Signed (1) The employer does not elect the employers’ liability coverage. Timothy Bruce Raleigh tim@raleighelectrical.org Same Des Moines Polk Iowa Joe Coughlon Genna Prine Signed
2189 2024-04-29 09:23 Anonymous (not verified) 94.188.207.225 Sals Home Improvements LLC Limited Liability Company 3750 NW Maple Ct Ankeny IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-29 Salvador Gomez salvadorg27@hotmail.com Ankeny Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Salvador Gomez salvadorg27@hotmail.com Self Ankeny Polk Iowa Fabiola Palomares Nathan Miller Signed
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
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
814 2021-12-27 13:07 Anonymous (not verified) 216.51.155.17 I & B Ag Supply, LLC Limited Liability Company 3807 20th Ave Fenton, IA 50539 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-27 Israel Winter israel.winter@hotmail.com Fenton Kossuth Iowa Jonathan Gesink Benjamin Wiersma Signed (1) The employer does not elect the employers’ liability coverage. Israel Winter israel.winter@hotmail.com Member Fenton Kossuth Iowa Jonathan Gesink Benjamin Wiersma Signed
1034 2022-04-05 11:43 Anonymous (not verified) 75.162.133.214 Riftworks Wood Manufactory Proprietorship 3807 Adams Ave, Des moines, Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-05 Bryan Siever bryan@siever.us Des Moines IA United States Cakeb Payne Tyler Anderson Signed (1) The employer does not elect the employers’ liability coverage. Bryan siever bryan@siever.us Business owner Des Moines IA United States Caleb Payne Tyler Anderson Signed
1494 2023-03-06 08:23 Anonymous (not verified) 94.188.207.223 James Douglas Clemons Proprietorship 3807 SW 3rd st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-06 james clemons james.clemons@grandview.edu des moines Iowa United States james clemons james clemons Signed (1) The employer does not elect the employers’ liability coverage. james clemons james.clemons@grandview.edu myself des moines Iowa United States james clemons james clemons Signed
433 2021-03-12 20:47 Anonymous (not verified) 173.28.1.65 HomeTeam painting llc Limited Liability Company 3810 Amherst Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-12 Johnny ollin johnnyollin@gmail.com DesMoines Polk IOWA David Carney Chad Winslow Signed (1) The employer does not elect the employers’ liability coverage. Johnny ollin johnnyollin@gmail.com Myself DesMoines Polk IOWA David Carney Chad Winslow Signed
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
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
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
19 2019-12-31 16:29 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Amar Music amarmusic01@gmail.com Owner Urbandale IA United States Sefik Music Amara Crncevic Signed
20 2019-12-31 16:36 Anonymous (not verified) 172.58.83.45 A.M. Tile Proprietorship 3824 122nd st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-12-31 Amar Music amarmusic01@gmail.com Urbandale IA United States Sefik Music Amara Crncevic Signed (1) The employer does not elect the employers’ liability coverage. Omer Okic ultimate.exteriors@gmail.com Owner Des Moines Polk IA Sefik Music Amara Crncevic Signed
446 2021-03-23 12:39 Anonymous (not verified) 174.198.72.209 Final Finish llc Limited Liability Company 3824 12th st Des Moines Iowa 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-23 Wesley Robert Detman wesdet@gmail.com Drs Moines Polk Iowa Leah Laxton Lucas Laxton Signed (1) The employer does not elect the employers’ liability coverage. Wesley Robert Detman wesdet@gmail.com Owner Des Moines Polk Iowa Leah Laxton Lucas Laxton Signed
171 2020-06-01 16:17 Anonymous (not verified) 99.203.98.130 Jose Jurado Limited Liability Company 3825 NE 43rd ct Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-01 Jose Jurado trustedroofingllc@gmail.com Des Moines Polk IOWA Sterling Bean Sigifredo Corral Signed (1) The employer does not elect the employers’ liability coverage. Jose Jurado trustedroofingllc@gmail.com Marcos Jurado Des Moines Polk IOWA Sterling Bean Sigifredo Corral Signed
1646 2023-05-15 13:13 Anonymous (not verified) 94.188.207.224 Aspen leaf Painting Limited Liability Company 3846 Lower Beaver Rd I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-15 Michael Patrick Vajda m.p.vajda@gmail.com Des Moines Polk IA Patrick Vajda Mike Vajda Signed (1) The employer does not elect the employers’ liability coverage. Mike Vajda m.p.vajda@gmail.com Self Des Moines Polk IA Mike Vajda Michael Vajda Signed
2197 2024-05-02 09:30 Anonymous (not verified) 94.188.207.229 Melvin Osorio Proprietorship 3848 E 14th St Trlr 78, Des Moines IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-02 Melvin Osorio matamorosana56@gmail.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Melvin Osorio matamorosana56@gmail.com Self Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
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
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
1601 2023-04-25 14:38 Anonymous (not verified) 94.188.207.230 francisco garcia Proprietorship 388 lesley ln ne I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-25 franscisco garcia frasicohinojosa@gmail.com cedar rapids linn iowa Ryan Klein Karina Jacobson Signed (1) The employer does not elect the employers’ liability coverage. francisco garcia frasicohinojosa@gmail.com N/A cedar rapids linn iowa Ryan Klein Karina Jacobson Signed
1841 2023-09-14 13:52 Anonymous (not verified) 94.188.207.225 Double M Construction LLC Limited Liability Company 3886 Diamond Rd, Elgin, IA 52141 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-16 Eli Miller elimiller@gmail.com Iowa Fayette Iowa Julie Schick Kelly Matt Signed (1) The employer does not elect the employers’ liability coverage. Eli Miller elimiller@gmail.com self Elgin Fayette Iowa Julie Schick Kelly Matt Signed
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
588 2021-07-27 19:59 Anonymous (not verified) 75.162.226.22 Andres Martinez Limited Liability Company 3903 SW 3rd St. Des Moines, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-27 Andres Martinez and.am12am@gmail.com Des Moines Polk Iowa Carla Martinez Librado Martinez Signed (1) The employer does not elect the employers’ liability coverage. Andres Martinez and.am12am@gmail.com Employer Des Moines Polk Iowa Carla Martinez Librado Martinez Signed
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
1050 2022-04-14 14:55 Anonymous (not verified) 173.18.22.217 L & L Home Solutions Limited Liability Company 3909 sw 14th st DSM IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Abraham LaMark landlhs@gmail.com des moines Polk IA Jen Lambert william schuldt Signed (1) The employer does not elect the employers’ liability coverage. Abraham LaMark landlhs@gmail.com friend des moines polk IA Jen LAmbert william schuldt Signed
1798 2023-08-14 12:16 Anonymous (not verified) 94.188.207.223 David Robles Proprietorship 3912 E 23rd St Des Moines, Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-09 David Robles deb@piciowa.com Des Moines Polk Iowa Debra E Stratton Kelly K Denger Signed (1) The employer does not elect the employers’ liability coverage. David Robles deb@piciowa.com self Des Moines Polk Iowa Kelly K Denger Debra E Stratton Signed
681 2021-10-19 15:44 Anonymous (not verified) 65.144.174.26 Humberto Albino Proprietorship 3914 Aurora Ave Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-19 Humberto Albino albinohumberto73@gmail.com Des Moines Polk Iowa Miguel Albino Jesus Albino Signed (1) The employer does not elect the employers’ liability coverage. Humberto Albino albinohumberto73@gmail.com Owner Des Moines Polk Iowa Miguel Albino Jesus Albino Signed
1878 2023-10-26 09:06 Anonymous (not verified) 94.188.205.168 Jones Facility Maintenance Limited Liability Company 3929 Council Street NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-25 Mason Jones jonesmason546@gmail.com Cedar Rapids IA United States Lindsey Jones Seth Wennermark Signed (1) The employer does not elect the employers’ liability coverage. Mason Bradley Jones jonesmason546@gmail.com Owner Cedar Rapids IA United States Lindsey Jones Seth Wennermark Signed
1896 2023-11-03 14:23 Anonymous (not verified) 94.188.207.225 Shane Adams Limited Liability Company 3944 54th st Des Moines,IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-03 Shane Steven Adams Shane6079@gmail.com Des Moines Polk Iowa Justin Mace Denice Sutton Signed (1) The employer does not elect the employers’ liability coverage. Shane Adams Shane6079@gmail.com Owner Des Moines Polk Iowa Justin Mace Denice Sutton Signed
356 2021-01-11 19:39 Anonymous (not verified) 66.188.136.150 David Whitfield Proprietorship 3947 Cracker Cove Lane I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-11 David Whitfield kschumacher@tricorinsurance.com Canal Winchester Fairfield OH Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. David Whitfield kschumacher@tricorinsurance.com Same Canal Winchester Fairfield OH Russell Masartis Nancy Wortley Signed
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
329 2020-12-01 10:02 Anonymous (not verified) 74.84.125.43 BRAINARD ROOFING & CONSTRUCTION COMPANY Limited Liability Company 4 South Ross St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-01 Cody Brainard brainardrcc2020@gmail.com Farmersburg Clayton United States Dave Moellers Jordan Cannon Signed (1) The employer does not elect the employers’ liability coverage. Cody Brainard brainardrcc2020@gmail.com I am the authorized agent & employer Farmersburg IA United States Dave Moellers Jordan Cannon Signed
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
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
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
1376 2022-11-18 10:22 Anonymous (not verified) 166.181.87.119 Ashley Heffernen Proprietorship 4009 Majestic Ct NE Cedar Rapids Iowa 52411 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-18 Ashley Rae Heffernen ashley.heffernen@gmail.com Cedar Rapids Linn Iowa Kyle Reid Amanda Frese Signed (1) The employer does not elect the employers’ liability coverage. Ashley Rae Heffernen ashley.heffernen@gmail.com Self Cedar Rapids Linn Iowa Kyle Reid Amanda Frese Signed
960 2022-03-09 11:13 Anonymous (not verified) 65.144.174.26 Jesus Munoz Proprietorship 401 6th Ave Coralville, IA 52241 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-09 Jesus Munoz jesus131805@gmail.com Coralville Johnson Iowa Juan Cruz Marlon Cruz Signed (1) The employer does not elect the employers’ liability coverage. Jesus Munoz jesus131805@gmail.com Self Coralville Johnson Iowa Juan Cruz Marlon Cruz Signed
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
1780 2023-08-03 16:50 Anonymous (not verified) 94.188.207.230 S-N-T BRINKMAN TRANSFER LLC Proprietorship 401 East Dewey Street Cassville, WI 53806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-01 Todd A Brinkman sntbrink@hotmail.com Cassville Wisconsin Wisconsin Todd A Brinkman Todd A Brinkman Signed (1) The employer does not elect the employers’ liability coverage. Todd A Brinkman sntbrink@hotmail.com Self employed Cassville Wisconsin Wisconsin Todd Brinkman Todd Brinkman Signed
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
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
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
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
2094 2024-03-14 10:16 Anonymous (not verified) 94.188.207.225 Timothy Deutmeyer Proprietorship 4014 iowa rd Center Point IA 52213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-14 Timothy Francis Deutmeyer timothydeutmeyer65@gmail.com Center Point Linn Iowa JAKE. Mcnurlaen Kevin Kinzebach Signed (1) The employer does not elect the employers’ liability coverage. Timothy Francis Deutmeyer timothydeutmeyer65@gmail.com Owner CENTER POINT Linn Iowa Jake Mcnurlaen Kevin Kinzebach 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
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
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
2080 2024-03-07 12:57 Anonymous (not verified) 94.188.205.168 Will's Bus Stuff LLC Limited Liability Company 402 SE Grant St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-07 Will Boettcher wboettcher@centurionstoneofiowa.com Des Moines Iowa United States Tyler Franklin Troy Klein Signed (1) The employer does not elect the employers’ liability coverage. Will Boettcher willsbusstuffllc@gmail.com Owner Ankeny Iowa United States Tyler Franklin Troy Klein Signed
806 2021-12-20 08:56 Anonymous (not verified) 50.124.217.66 Lyndon L Giese dba G&G Farms Trucking Proprietorship 402 St Olaf Ave S Canby, MN 56220 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-20 Lyndon L Giese ldgiese@frontiernet.net Canby Yellow Medicine Minnesota Jeff Sinn Tiffany Gohr Signed (1) The employer does not elect the employers’ liability coverage. Lyndon L Giese ldgiese@frontiernet.net Owner Canby Yellow Medicine Minnesota Jeff Sinn Tiffany Gohr Signed
1807 2023-08-17 12:45 Anonymous (not verified) 94.188.205.175 LONE STAR ROOFING, LLC Limited Liability Company 4021 WINDSOR CT DES MOINES, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-17 RAQUEL B DIAZ MENENDEZ LONE.STAR.ROOFING76@GMAIL.COM DES MOINES USA IOWA LILIANA SANCHEZ RENE ALEXANDER VELASCO Signed (1) The employer does not elect the employers’ liability coverage. LONE STAR ROOFING, LLC LONE.STAR.ROOFING76@GMAIL.COM MEMBER OWNER DES MOINES USA IOWA LILIANA SANCHEZ RENE ALEXANDER VELASCO Signed
63 2020-02-17 16:05 Anonymous (not verified) 173.17.12.213 ANA GARCIA GONZALEZ Limited Liability Company 4023 14TH ST DES MOINES IOWA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-17 Ana Garcia Gonzalez gjeanettegonzalez@gmail.com DES MOINES POLK IOWA LUZ SAUCEDA SANDRA ISABEL SAUCEDA Signed (1) The employer does not elect the employers’ liability coverage. ANA GARCIA GONZALEZ GJEANETTEGONZALEZ@GMAIL.COM SELF DES MOINES POLK IA LUZ SOTELO SAUCEDO SANDRA ISABEL SAUCEDA Signed
163 2020-05-20 11:58 Anonymous (not verified) 173.27.1.111 David Proprietorship 4023 E 28th st 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-20 David Ortiz jdiconstrucction@gmail.com Des Moines Polk County Iowa Erika Olague Jieldh Ortiz-Olague Signed (1) The employer does not elect the employers’ liability coverage. David Ortiz jdiconstrucction@gmail.com JDI Construction Des Moines Polk County Iowa Erika Olague Jieldh Ortiz-Olague Signed
1677 2023-06-02 11:37 Anonymous (not verified) 94.188.207.230 Karl Klotzbach Proprietorship 403 Jefferson, Decorah IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-02 Karl Klotzbach kdklotzbach@gmail.com Decorah Winneshiek Iowa Robin Schultz Jane Regan Signed (1) The employer does not elect the employers’ liability coverage. Karl Klotzbach kdklotzbach@gmail.com Employer Decorah Winneshiek Iowa Robin Schutlz Jane M Regan Signed
2045 2024-02-15 10:26 Anonymous (not verified) 94.188.207.227 Francesco Martinez Proprietorship 403th 7th Ave NW Clarion IA 50525 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-15 Francesco Martinez Martinexfrancesco99@gmail.com Clarion Wright Iowa Jason W Helmers Josh W Helmers Signed (1) The employer does not elect the employers’ liability coverage. Francesco Martinez martinezfrancesco99@gmail.com Employer Clarion Wright Iowa Jason W Helmers Josh W Helmers Signed
134 2020-04-28 08:15 Anonymous (not verified) 66.188.136.150 Lowell Fenton Proprietorship 404 1/2 W Main St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-27 Lowell Fenton fentonlowell@gmail.com Decorah Winneshiek IA Russell Masartis Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Lowell Fenton kschumacher@tricorinsurance.com Same person Decorah Winneshiek IA Russell Masartis Shuree Behr Signed
1005 2022-03-24 14:34 Anonymous (not verified) 165.225.57.246 Beardmore Construction Limited Liability Company 404 E 1st Ave Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Nathan Fosenburg nfosenburg@yahoo.com Indianola Warren IA Kerri Fosenburg Nathan Fosenburg Signed (1) The employer does not elect the employers’ liability coverage. Nathan Fosenburg nfosenburg@yahoo.com owner Indianola Warren IA Kerri Fosenburg Nathan Fosenburg Signed
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
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
1506 2023-03-08 15:12 Anonymous (not verified) 94.188.207.226 Heritage Towing LLC Limited Liability Company 404 Sherman Ave. Ackley Iowa 50601 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-08 Jeff Brass heritagemotors17@yahoo.com Ackley Hardin Iowa Joellen Reynolds Linzie Morris Signed (1) The employer does not elect the employers’ liability coverage. Jeff Brass hertiagemotors17@yahoo.com Member of LLC Ackley Hardin Iowa JoEllen Reynolds Linzie Morris Signed
1770 2023-07-31 14:21 Anonymous (not verified) 94.188.205.168 D & G Communications Proprietorship 405 1st St N., PO Box 11 Farley, Iowa 52046 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-31 Dave Hirsch dngcomm@hotmail.com Farley Dubuque Iowa Zack Hirsch Nick Hirsch Signed (1) The employer does not elect the employers’ liability coverage. Dave Hirsch dngcomm@hotmail.com self Farley Dubuque Iowa Zach Hirsch Nick Hirsch Signed
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
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
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
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
1085 2022-05-03 10:38 Anonymous (not verified) 65.144.174.26 Caleb Schroeder Proprietorship 4051 SW 56th St Des Moines, IA 50321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-03 Caleb Schroeder calebpschroeder@gmail.com Des Moines Polk Iowa Michele Schroeder Donald Schroeder Signed (1) The employer does not elect the employers’ liability coverage. Caleb Schroeder calebpschroeder@gmail.com Self Des Moines Polk Iowa Michele Schroeder Donald Schroeder Signed
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
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
1409 2023-01-05 11:55 Anonymous (not verified) 173.23.88.7 Top tier gutter systems llc Limited Liability Company 405a 1st Ave sw Cedar Rapids, ia I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-05 Rocky layne smith toptierguttersystems@yahoo.com Cedar Rapids Linn IA Faye momodu Rocky smith Signed (1) The employer does not elect the employers’ liability coverage. Rocky smith toptierguttersystems@yahoo.com Self Cedar Rapids Linn IA Faye momodu Derrick Signed
1613 2023-04-27 13:57 Anonymous (not verified) 94.188.207.227 Jacob's Ladder Construction Proprietorship 406 10th st Dallas Center Ia 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-27 Jacob Willis jwillis924@gmail.com Dallas Center IA United States Anibal Bonilla Ed Willis Signed (1) The employer does not elect the employers’ liability coverage. Jacob A Willis jwillis924@gmail.com Owner Dallas Center IA United States Anibal Bonilla Ed Willis Signed
857 2022-01-26 16:27 Anonymous (not verified) 207.199.212.86 Grahm's Tree Service Proprietorship 406 2nd Ave Charles City, IA 50616 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-22 Graham Kuethe lacy@cioia.com Charles City Floyd Iowa Lacy Carolan Tony Trower Signed (1) The employer does not elect the employers’ liability coverage. Graham Kuethe lacy@cioia.com Owner Charles City Floyd Iowa Lacy Carolan Tony Trower Signed
37 2020-01-16 15:26 Anonymous (not verified) 173.24.236.134 Eric Krueger Proprietorship 406 NE Oak Dr. Ankeny, IA 50021 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-16 Eric Lucas Krueger erickrugs@gmail.com Ankeny Polk Iowa Emily Marie Krueger Roberty William Krueger Signed (1) The employer does not elect the employers’ liability coverage. Eric Krueger erickrugs@gmail.com self Ankeny Polk Iowa Emily Marie Krueger Robert William Krueger Signed
351 2021-01-06 16:20 Anonymous (not verified) 173.25.23.170 Eric Krueger Proprietorship 406 NE Oak Dr. Ankeny, IA 50021 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-07 Eric Lucas Krueger erickrugs@gmail.com Ankeny Polk Iowa Emily Marie Krueger Robert William Krueger Signed (1) The employer does not elect the employers’ liability coverage. Eric Lucas Krueger erickrugs@gmail.com self Ankeny Polk Iowa Emily Marie Krueger Robert William Krueger Signed
826 2022-01-10 12:26 Anonymous (not verified) 104.128.43.204 Wolfman Trucking, LLC Limited Liability Company 406 S Lawrence St, Bazine, KS 67516 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-10 JR Steckline wolfmantrucking317@gmail.com Bazine Ness Kansas James Babcock Darin Wittman Signed (1) The employer does not elect the employers’ liability coverage. JR Steckline wolfmantrucking317@gmail.com Owner Bazine Ness Kansas James Babcock Darin Wittman Signed
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
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
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
1051 2022-04-14 17:56 Anonymous (not verified) 199.59.236.46 Triple M Welding Proprietorship 407 4th St Sw I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Matthew Gibson matthew.gibson02003@gmail.com Independence Iowa Iowa Brandon Keener Cody Laughlin Signed (1) The employer does not elect the employers’ liability coverage. Matthew Gibson matthew.gibson02003@gmail.com Owner Independence Iowa Iowa Brandon Keener Cody Laughlin Signed
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
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
764 2021-11-22 15:33 Anonymous (not verified) 198.14.219.227 Central Iowa Painting and Contracting LLC Limited Liability Company 408 Freel Drive, Ste. 101, Ames, IA 50010 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-22 Matthew Paul Klucas mklucas50@gmail.com Fort Dodge Webster County Iowa Jordan Watkins Scott Schuler Signed (1) The employer does not elect the employers’ liability coverage. Matthew Klucas mklucas50@gmail.com Owner of Buisness Fort Dodge Webster County Iowa Jordan Watkins Scott Schuler Signed
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
1492 2023-03-03 16:09 Anonymous (not verified) 94.188.207.229 Sean Aldrich LLC Limited Liability Company 408 n.7th st. Indianola iowa 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-03 Sean Kenneth Aldrich sean.aldrich74@gmail.com Indianola Warren Iowa Madeline Jenelle Aldrich John Thomas Aldrich Signed (1) The employer does not elect the employers’ liability coverage. Sean Kenneth Aldrich sean.aldrich74@gmail.com Self Indianola Warren Iowa Madeline Jenelle Aldrich John Thomas Aldrich Signed
1122 2022-05-21 12:19 Anonymous (not verified) 173.24.108.210 Daly Building Service,LLc Limited Liability Company 409 Dammann dr. Eldridge IA, 52748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-21 Noah Daly Noahdalyubs@gmail.com Eldridge Scott County Iowa Holly Roberts Corinna Daly Signed (1) The employer does not elect the employers’ liability coverage. Derick Perry biglakellc@outlook.com Liability policy agent Eldridge Scott county Iowa Holly roberts Corinna Daly Signed
1123 2022-05-22 14:32 Anonymous (not verified) 173.24.108.210 Daly Building Service, LLC Limited Liability Company 409 Dammann Dr. Eldridge IA. 52748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-22 Noah Taylor Daly Noahdalyubs@Gmail.com Eldridge Scott County Iowa Corinna Daly Holly Roberts Signed (1) The employer does not elect the employers’ liability coverage. Noah Taylor Daly Noahdalyubs@Gmail.com Owner Eldridge Scott County Iowa Corinna Daly Holly Roberts Signed
1863 2023-10-06 12:24 Anonymous (not verified) 94.188.207.223 ADRIAN CAZARES HERNANDEZ Proprietorship 409 N 16TH PL, ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-06 ADRIAN CAZARES HERNANDEZ JOEL@WALKERINSURANCE.COM ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. ADRIAN CAZARES HERNANDEZ JOEL@WALKERINSURANCEIA.COM SELF ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
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
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
140 2020-04-28 10:13 Anonymous (not verified) 74.84.101.138 Lutheran Cemetery Association Proprietorship 410 S. Mechanic Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-21 John D Noel chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed (1) The employer does not elect the employers’ liability coverage. John D Noel chelsea.whalen@upperiowains.com President Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed
141 2020-04-28 10:14 Anonymous (not verified) 74.84.101.138 Lutheran Cemetery Association Proprietorship 410 S. Mechanic Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-02 Steven Matter chelsea.whalen@upperiowains.com Decorah Winneshiek IA Bobbi Jo Berg Robin C Schultz Signed (1) The employer does not elect the employers’ liability coverage. Steven Matter chelsea.whalen@upperiowains.com Secretary Decorah Winneshiek IA BOBBI JO BERG Robin C Schultz Signed
142 2020-04-28 10:16 Anonymous (not verified) 74.84.101.138 Lutheran Cemetery Association Proprietorship 410 S. Mechanic Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-18 Timothy A Stoddard chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed (1) The employer does not elect the employers’ liability coverage. Timothy A Stoddard chelsea.whalen@upperiowains.com Treasurer Decorah Winneshiek IA Robin C Schultz Bobbi Jo Berg Signed
1068 2022-04-25 06:07 Anonymous (not verified) 172.58.84.213 Alondra Canedo Orta Limited Liability Company 4100 Hubbell Ave Apt#80 Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-25 Alondra Canedo Orta alondracanedo34@gmail.com Des Moines Polk county Iowa Marvin Bonilla Alondra Canedo Signed (1) The employer does not elect the employers’ liability coverage. Alondra Canedo Orta alondracanedo34@gmail.com Subcontractor Installer Des Moines Polk county Iowa Marvin Bonilla Alondra Canedo Signed
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
449 2021-03-25 10:53 Anonymous (not verified) 174.198.73.94 A&F Painting llc Limited Liability Company 411 E Dunham ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-25 Miguel Afanador Olguin mafanador02@gmail.com Des Moines Polk Iowa Alfonzo Afanador Noemi Afanador Signed (1) The employer does not elect the employers’ liability coverage. Miguel Afanador Olguin mafanador02@gmail.com Owner Des Moines Polk Iowa Alfonzo Alfanador Noemi Alfanador Signed
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
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
1449 2023-02-11 10:37 Anonymous (not verified) 94.188.207.227 Luxury Home Improvements Limited Liability Company 4117 Boyd st Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-11 Luis A Hernandez luxuryhomes.iowa@gmail.com Des Moines Polk Iowa Maria T Lopez Josmar Hernandez Signed (1) The employer does not elect the employers’ liability coverage. Luis A Hernandez luxuryhomes.iowa@gmail.com Self Des Moines Polk Iowa Maria T Lopez Josmar Hernandez Signed
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
1019 2022-03-29 16:42 Anonymous (not verified) 104.201.100.158 Nayeri Group LLC Limited Liability Company 412 SE 17th Court, Grimes, Iowa 50111 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-29 Sima Dehghan Nayeri nayeri.sima@gmail.com Grimes Polk Iowa Jacob Willis Lucas Peterson Signed (1) The employer does not elect the employers’ liability coverage. Sima Nayeri nayeri.sima@gmail.com Self Grimes Polk Iowa Jacob Willis Lucas Peterson Signed
1713 2023-06-27 09:06 Anonymous (not verified) 94.188.205.175 Ray's Painters, LLC Limited Liability Company 4120 Mount Alpine Street, Dubuque, IA 52001 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-15 Danny Sexton dsexton766@gmail.com Dubuque Dubuque Iowa Donna Gotto Brenda Lewis Signed (1) The employer does not elect the employers’ liability coverage. Ray's Painters LLC dsexton766@gmail.com insured Dubuque Dubuque Iowa Donna Gotto Brenda Lewis Signed
2064 2024-02-29 11:53 Anonymous (not verified) 94.188.207.227 Quality Masonry LLC Limited Liability Company 4121 14th 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. 2024-02-29 Wilian Nunez williamnunez77@gmail.com Des Moines IOWA United States Drake Rapaich Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Wilian Nunez Williamnunez77@gmail.com Self Des Moines Polk IA Drake Rapaich Nathan Miller Signed
1598 2023-04-25 07:02 Anonymous (not verified) 94.188.205.174 Johnny Pommer Limited Liability Company 4125, E 30th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-25 Johnny Pommer bravojohnny@me.com Des Moines United states IA Johnny Pommer Kimberly pommer Signed (1) The employer does not elect the employers’ liability coverage. Johnny Pommer bravojohnny@me.com Owner Des Moines United States IA Johnny Pommer Kimberly pommer Signed
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
1800 2023-08-14 20:24 Anonymous (not verified) 94.188.207.227 Laven Snow Removal LLC Limited Liability Company 413 SE 6th street Ankeny, IA 50021 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-14 Myles John Laven lavensnowremoval@gmail.com Ankeny Polk Iowa Megan Rose Nefzger Mackale Joel Laven Signed (1) The employer does not elect the employers’ liability coverage. Myles John Laven lavensnowremoval@gmail.com Owner Ankeny Polk Iowa Megan Rose Nefzger Mackale Joel laven Signed
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
1095 2022-05-12 13:20 Anonymous (not verified) 173.31.29.53 Leaf cutter protection Limited Liability Company 4146 East 23rd Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-05-12 Gideon Lagat gsaina78@gmail.com Des Moines IA United States Priscilla saina Cosmas nyaika Signed (1) The employer does not elect the employers’ liability coverage. Mark rond mbond@leaffilter.com Regional installation Manager Grimes Polk Iowa Priscilla saina Cosmas nyaika Signed
1919 2023-11-21 14:11 Anonymous (not verified) 94.188.207.227 Refined Construction Limited Liability Company 4148 Mattern ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-21 Dustin Martin dudtin.martin106@gmail.com Des Moines Polk IA Kelsey Baldinelli Brandi Martin Signed (1) The employer does not elect the employers’ liability coverage. Dustin Martin dustin.martin106@gmail.com Sole officer Des Moines Polk IA Kelsey Baldinelli Brandi Martin Signed
2073 2024-03-04 15:51 Anonymous (not verified) 94.188.207.227 JACOB HANSON Proprietorship 415 N 18TH ST ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-04 JACOB HANSON HANSONONEBOY@GMAIL.COM ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. JACOB HANSON HANSONONEBOY@GMAIL.COM SELF ESTHERVILLE EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
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
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
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
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
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
1083 2022-05-02 13:42 Anonymous (not verified) 173.18.233.175 John Helm Proprietorship 417 Pleasant Hill DR Atkins, IA 52206 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-02 John Helm johnhelmconstruction22@gmail.com Atkins Benton Iowa Brian Ashlock Trevor Vick Signed (1) The employer does not elect the employers’ liability coverage. John Helm johnhelmconstruction22@gmail.com Owner Atkins Benton IOWA Brian Ashlock Trevor Vick Signed
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
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
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
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
879 2022-01-31 14:26 Anonymous (not verified) 173.27.146.201 Premier Window Cleaning LLC Limited Liability Company 420 E GRANGER AVE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-31 Frank Viola premierofiowa@gmail.com DES MOINES IA United States Ron Reynolds Chris Greco Signed (1) The employer does not elect the employers’ liability coverage. Frank Viola premierofiowa@gmail.com my self DES MOINES IA United States Ron Reynolds Chris Greco Signed
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
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
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
1309 2022-09-15 09:58 Anonymous (not verified) 96.31.1.206 PATTONS POWDER COATING Limited Liability Company 421 W MAPLE DRIVE HARTLEY IA 51346 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-15 DAVID PATTON PATTONSPOWDERCOATING@GMAIL.COM HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. PATTONS POWDER COATING - DAVID PATTON PATTONSPOWDERCOATING@GMAIL.COM SELF HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNG WIRTH Signed
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
1570 2023-04-12 18:09 Anonymous (not verified) 94.188.205.166 Staley Engineering Consultants, LLC Limited Liability Company 4212 Holland Drive, Des Moines, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-12 Donald K Staley Don.Staley@q.com Des Moines Iowa United States Kendall S. Staley Gary D. Hlavka Signed (1) The employer does not elect the employers’ liability coverage. Donald K Staley Don.Staley@q.com Owner Des Moines Iowa United States Kendall S. Staley Gary D. Hlavka Signed
942 2022-03-02 18:52 Anonymous (not verified) 173.16.196.70 Mason Cooper Limited Liability Company 4213 Southwest 23rd Place I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-02 Mason Cooper koupenc5@icloud.com Des Moines Polk IA Savannah Cooper Norman Weathers Signed (1) The employer does not elect the employers’ liability coverage. Mason Cooper koupenc5@icloud.com Myself Des Moines Polk IA Savannah Cooper Norman Weathers Signed
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
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
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
1052 2022-04-14 19:05 Anonymous (not verified) 140.82.187.220 McHaddy Constuction Proprietorship 423 Railroad St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 Mick Haddeman mick@mchaddyconstruction.com Hudson Iowa United States Linsey Jo Haddeman Jordan Renae Haddeman Signed (1) The employer does not elect the employers’ liability coverage. Michael Haddeman mick@mchaddyconstruction.com self Hudson IA United States Linsey Jo Haddeman Jordan Renae Haddeman Signed
2122 2024-03-28 10:15 Anonymous (not verified) 94.188.205.169 Stone Villalobos LLC Limited Liability Company 4231 Morton Ave Des Moines Iowa 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-28 Josue Villalobos villalobosjosue2016@gmail.com Des Moines Polk Iowa Edgar Palomares Fabiola Palomares Recendiz Signed (1) The employer does not elect the employers’ liability coverage. Josue Villalobos villalobosjosue2016@gmail.com Self Des Moines Polk Iowa Edgar Palomares Fabiola Palomares Recendiz Signed
1351 2022-10-31 16:36 Anonymous (not verified) 75.231.74.186 Spencer C Nash LLC Limited Liability Company 4233 Pineview Dr NE, Cedar Rapids, IA 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-31 Spencer Nash spencer@optionsexteriors.com Cedar Rapids Linn County Iowa Charlotte Rasmussen Austin Miller Signed (1) The employer does not elect the employers’ liability coverage. Spencer Nash spencer@optionsexteriors.com Owner/Self Cedar Rapids Linn County Iowa Charlotte Rasmussen Austin Miller Signed
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
477 2021-04-14 11:04 Anonymous (not verified) 65.103.82.36 Lisa Kuhn Proprietorship 427 s Concord Davenport IA 52802 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-09 Lisa Kuhn none@hotmail.com davenport Scott IA Sarah Erick Signed (1) The employer does not elect the employers’ liability coverage. Lisa Kuhn none@hotmail.com self davenport scott IA sarah erick Signed
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
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
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
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
1029 2022-04-04 12:46 Anonymous (not verified) 174.215.242.124 Bonnie Seely Proprietorship 43 rainbow court se Cedar Rapids Iowa 52403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-04 Bonnie Elizabeth seely bseely4@gmail.com Cedar Rapids Linn Iowa Mikaela Seely Noah seely Signed (1) The employer does not elect the employers’ liability coverage. Bonnie Seely bseely4@gmail.com Self Cedar Rapids IA United States Mikaela Seely Noah Seely Signed
1971 2023-12-29 19:27 Anonymous (not verified) 94.188.207.223 Megan Thibodeau Proprietorship 4301 Adams Ave, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-29 Megan E Thibodeau megancallan@hotmail.com Des Moines Iowa United States Travis Releford Courtney Releford Signed (1) The employer does not elect the employers’ liability coverage. Megan E Thibodeau megancallan@hotmail.com Self Des Moines Iowa United States Travis Releford Courtney Releford Signed
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
2068 2024-03-01 09:53 Anonymous (not verified) 94.188.207.226 A-1 Stone LLC Limited Liability Company 4308 Boyd St Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-01 Orlando Nunez nunezstone@gmail.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Perla Patricia Nunez nunezstone@gmail.com Employee Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
2069 2024-03-01 09:55 Anonymous (not verified) 94.188.207.226 A-1 Stone LLC Limited Liability Company 4308 Boyd St Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-01 Orlando Manuel Nunez Mejia orlando20025@gmail.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Perla Patricia Nunez nunezstone@gmail.com Employee Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
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
1599 2023-04-25 14:38 Anonymous (not verified) 94.188.207.229 luis contreras Proprietorship 433 8th ave sw I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-25 luis contreras luisayala781@gmail.com cedar rapids linn iowa Ryan Klein Karina Jacobson Signed (1) The employer does not elect the employers’ liability coverage. luis contreras luisayala781@gmail.com N/A cedar rapids linn iowa Ryan Klein Karina Jacobson Signed
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
1491 2023-03-03 11:24 Anonymous (not verified) 94.188.207.224 Ray gist Proprietorship 4330 nw 9th st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-03 Raymond Rex Gist rrgist8@yahoo.com Dsm Polk Ia Amber Gist Victor Brawdy Signed (1) The employer does not elect the employers’ liability coverage. Raymond Rex Gist rrgist8@yahoo.com Same person Dsm Polk Ia Amber Gist Victor Brawdy Signed
150 2020-05-06 10:59 Anonymous (not verified) 76.190.229.163 RNR Holdings LLC Limited Liability Company 4330 Winter Eagle Trail SE Apt B, Iowa City, Iowa 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-06 Richard E. White rwhite245@yahoo.com Hermitage Mercer Pennsylvania Gene Bell Victor J Veltri Signed (1) The employer does not elect the employers’ liability coverage. Richard E White rwhite245@yahoo.com Owner Hermitage Mercer Pennsylvania Gene Bell Victor J Veltri Signed
2164 2024-04-19 13:52 Anonymous (not verified) 94.188.205.167 RKB Designs LLC Limited Liability Company 4333 Cedar St, Davenport, IA 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-19 Ashley Rocca roccafive@gmail.com Davenport IA United States Nicholas Rocca Joni Long Signed (1) The employer does not elect the employers’ liability coverage. Ashley Rocca roccafive@gmail.com Self Davenport IA United States Nicholas Rocca Joni Long Signed
485 2021-04-16 11:58 Anonymous (not verified) 69.57.23.123 CRAIG AUKES Proprietorship 43397 50TH AVENUE, BUFFALO CENTER, IA 50424 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-16 CRAIG AUKES cdaukes@yahoo.com Buffalo Center Winnebago Iowa Steven Heyer Cindy Mawdsley Signed (1) The employer does not elect the employers’ liability coverage. CRAIG AUKES cdaukes@yahoo.com Employer-Proprietor Buffalo Center Winnebago IA Steven Heyer Cindy Mawdsley Signed
534 2021-06-04 12:47 Anonymous (not verified) 192.119.129.187 KMA Communications, LLC Limited Liability Company 435 croston rd. Stockport, OH 43787 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-04 Matthew Razen Alsup malsupbrgi@gmail.com Stockport Morgan Ohio Stephen Alsup Nancy Alsup Signed (1) The employer does not elect the employers’ liability coverage. Matthew Razen Alsup malsupbrgi@gmail.com Same person Stockport Morgan Ohio Stephen Alsup Nancy Alsup Signed
535 2021-06-04 13:16 Anonymous (not verified) 192.119.129.187 KMA Communications, LLC Limited Liability Company 435 croston rd. Stockport, OH 43787 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-04 Kenneth Stephen Alsup kenneth.alsup@yahoo.com Walker Wood West Virginia Stephen Alsup Nancy Alsup Signed (1) The employer does not elect the employers’ liability coverage. Kenneth Stephen Alsup kenneth.alsup@yahoo.com Same Person Walker Wood West Virginia Stephen Alsup Nancy Alsup Signed
1802 2023-08-15 15:23 Anonymous (not verified) 94.188.205.174 NORTH STARS, LLC Limited Liability Company 4374 STATE ST STE 2 BETTENDORF, IA 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-15 JOSE A DURAN MORALES northstarsllcmn@gmail.com BETTENDORF USA IOWA ARMANDO DURAN LILIANA SANCHEZ Signed (1) The employer does not elect the employers’ liability coverage. NORTH STARS, LLC northstarsllcmn@gmail.com BUSINESS OWNER BETTENDORF USA IOWA LILIANA SANCHEZ ARMANDO DURAN Signed
233 2020-08-17 14:24 Anonymous (not verified) 165.225.0.98 Daniel L Knebel Proprietorship 439 Carroll Blvd, Dunkerton, IA, 50626 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-17 Daniel L Knebel knebeldan@gmail.com Dunkerton Black Hawk Iowa Carman M Knebel Joseph E Knebel Signed (1) The employer does not elect the employers’ liability coverage. Daniel L Knebel knebeldan@gmail.com Owner Dunkerton Black Hawk Iowa Carman M Knebel Joseph E Knebel Signed
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
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
714 2021-11-05 11:16 Anonymous (not verified) 209.252.172.87 Branson Bult - Bults Flooring Proprietorship 440 Memorial Dr Se Cedar Rapids, Ia 52403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-16 Branson Bult bultsfloorcovering@gmail.com Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Branson Bult bultsfloorcovering@gmail.com Self Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed
2066 2024-02-29 15:27 Anonymous (not verified) 94.188.207.230 Julian Abey Proprietorship 4405 NW Abilene Road, Ankeny IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-29 Julian Abey Jabeyhpro@gmail.com Ankeny Polk IA Eric Ndifon Peter Gara Signed (1) The employer does not elect the employers’ liability coverage. Julian Abey Jabeyhpro@gmail.com Self Ankeny IA IA Eric Ndifon Peter Gara Signed
5 2019-11-12 09:57 Anonymous (not verified) 174.71.54.19 M AND J LLC Limited Liability Company 44100 STATE HIGHWAY 37 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-12 M AND J, LLC mknichols2003@yahoo.com DUNLAP MONONA IA Damon Nichols Bob Hall Signed (1) The employer does not elect the employers’ liability coverage. JAMES MUMM plipichok@yahoo.com Partner DUNLAP MONONA IA DAMON NICHOLS BOB HALL Signed
4 2019-11-12 09:06 Anonymous (not verified) 174.71.54.19 M AND J LLC Limited Liability Company 44100 STATE HIGHWAY 37 Dunlap, IA 51529 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-12 Mark Nichols mknichols2003@yahoo.com DUNLAP Monona IA Damon Nichols Bob Hall Signed (1) The employer does not elect the employers’ liability coverage. Mark Nichols mknichols2003@yahoo.com Partner Dunlap Monona IA Damon Nichols Bob Hall Signed
43 2020-01-27 09:23 Anonymous (not verified) 71.199.85.251 ATW Training Limited Liability Company 4414 114th Street, Urbandale Iowa 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-25 Heather Hampton Cooper hcooper1@comcast.net Saint Augustine Saint Johns Florida Terry Lee Cooper Stacy Thatcher Signed (1) The employer does not elect the employers’ liability coverage. Lynn Roberts Lynne@atwtraining.com HR Des Moines Polk Iowa Cathy Belmont Mark Purcell Signed
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
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
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
1965 2023-12-22 10:23 Anonymous (not verified) 94.188.207.229 Shawn Cooney Proprietorship 4425 Ne 34th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-22 Shawn Nelson Cooney shawncooney59@gmail.com Des Moines polk IA Marie Cooney Shawntel Cooney Signed (1) The employer does not elect the employers’ liability coverage. Shawn Cooney shawncooney59@gmail.com Myself Des Moines polk IA Marie Cooney Shawntel Cooney Signed
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
337 2020-12-11 21:56 Anonymous (not verified) 66.129.217.166 Tabora Perez Minerva Proprietorship 4494 Taft Ave SE Trl. 1B Iowa City, IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-12-01 Tabora Perez Minerva tonypauljohnson@yahoo.com Iowa City Johnson Iowa Anthony Johnson Rafael Donis Signed (1) The employer does not elect the employers’ liability coverage. Tabora Perez Minerva tonypauljohnson@yahoo.com Agent Iowa City Johnson IA Anthony Johnson Rafael Donis Signed
863 2022-01-27 12:13 Anonymous (not verified) 174.198.81.166 Big Bear Construction llc Limited Liability Company 4508 Hiawatha Ave ne Cedar Rapids iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-27 Kevin Paul Becker jr kbeckerbbc@gmail.com Cedar Rapids Linn Iowa Kenny McCracken Corey Becker Signed (1) The employer does not elect the employers’ liability coverage. Michael Allen Becker mike4bbc@gmail.com Brother/Partner Cedar Rapids Linn Iowa Kenny McCracken Corey Becker Signed
862 2022-01-27 12:02 Anonymous (not verified) 174.198.81.166 Big Bear Construction,LLC Limited Liability Company 4508 Hiawatha Ave NE Cedar Rapids, IA 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-27 Michael Allen Becker mike4bbc@gmail.com Cedar Rapids Linn Iowa Kenny McCracken Corey Becker Signed (1) The employer does not elect the employers’ liability coverage. Kevin Paul Becker jr kbeckerbbc@gmail.com Brother/partner Cedar Rapids Linn Iowa Kenny McCracken Corey Becker Signed
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
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
1190 2022-07-07 12:00 Anonymous (not verified) 172.243.111.71 Breuer Earthworks Inc. Proprietorship 4512 148th Ave 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. 2022-07-07 William Breuer breuerearthworks@gmail.com Burlington Des Moines Iowa Donald Breuer Ericka Breuer Signed (1) The employer does not elect the employers’ liability coverage. William Breuer breuerearthworks@gmail.com Owner of Breuer Earthworks Inc. BURLINGTON Iowa United States Donald Breuer Ericka Breuer 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
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
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
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
1217 2022-07-21 06:51 Anonymous (not verified) 209.152.88.53 Bullard Accounting Services, LLC Limited Liability Company 4519 Scouts View Dr, Central City, IA 52214 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-21 Michael Bullard mikeandkarenbullard@gmail.com CENTRAL CITY IA United States Karen Bullard Nicole Nassif Signed (1) The employer does not elect the employers’ liability coverage. Michael Bullard mikeandkarenbullard@gmail.com President of Company CENTRAL CITY IA United States Karen Bullard Nicole Nassif Signed
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
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
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
2023 2024-02-05 21:11 Anonymous (not verified) 94.188.205.176 Joey Pohlen Proprietorship 4552 400th St. Hospers, Iowa 51238 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-05 Joseph Dale Pohlen joey.pohlen18@gmail.com Hospers Sioux Iowa Joseph Clarence Pohlen Steven Laurence Auchstetter Signed (1) The employer does not elect the employers’ liability coverage. Joseph Dale Pohlen joey.pohlen18@gmail.com owner Hospers Sioux Iowa Joseph Clarence Pohlen Steven Laurence Auchstetter Signed
1213 2022-07-19 14:00 Anonymous (not verified) 198.14.220.143 VLG Build & Remodle LLC Limited Liability Partnership 45547 State HWY 14 Chariton, IA 50049 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-07-19 Vladimir Golosinskiy VLGCONSTRUCTION@YAHOO.COM Chariton IA United States Vladimir Golosinskiy Vladimir Golosinskiy Signed (1) The employer does not elect the employers’ liability coverage. LILIA GOLOSINSKIY VLGCONSTRUCTION@YAHOO.COM Wife CHARITON Iowa United States LILIA GOLOSINSKIY LILIA GOLOSINSKIY Signed
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
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
941 2022-03-02 09:06 Anonymous (not verified) 173.18.150.140 515 Trucking, L.L.C. Limited Liability Company 4613 E Valdez Dr, Des Moines IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-02 Thomas L Garrett 515TruckHaul@gmail.com Des Moines Polk Iowa Shelley L Garrett Sheila J Wyman Signed (1) The employer does not elect the employers’ liability coverage. Thomas L Garrett 515TruckHaul@gmail.com Owner Des Moines Polk Iowa Shelley L Garrett Sheila J Wyman Signed
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
246 2020-08-25 15:36 Anonymous (not verified) 97.125.173.2 MPT plumbing Limited Liability Company 4616 147th st urbandale, ia 50323 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-25 justin lee tigges tplumbing3@aol.com urbandale dallas iowa insurance is a scam I would get a different issurance company Signed (1) The employer does not elect the employers’ liability coverage. grinnell mutual lori@grinnellmutual.com insurance agent i dont know I don't know iowa what a pain in the ass This makes no sense Signed
1651 2023-05-16 22:18 Anonymous (not verified) 94.188.205.175 Corridor Cleaning Services, LLC Limited Liability Company 4621 Orchard Dr NW, Cedar Rapids, Iowa, 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-11 Andrew Kleineck andrew@corridorcleaning.net Cedar Rapids Linn Iowa Cole Smith Suzanne Brue Signed (1) The employer does not elect the employers’ liability coverage. Andrew Kleineck andrew@corridorcleaning.net LLC Member Cedar Rapids Linn Iowa Cole Smith Suzanne Brue Signed
202 2020-07-10 15:30 Anonymous (not verified) 50.82.95.247 Paulo De Oliveira Proprietorship 466 Valeen In Belton, MO 64012 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-10 Paulo De Oliveira paulinhousa1981@gmail.com Belton Cass Missouri Deanna K Yersin Ryan S. Johnson Signed (1) The employer does not elect the employers’ liability coverage. Paulo De Oliveira paulinhousa1981@gmail.com paulinhousa1981@gmail.com Belton Cass Missouri Deanna K Yersin Ryan S. Johnson Signed
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
1948 2023-12-11 10:36 Anonymous (not verified) 94.188.207.224 Just Like New Details LLC Limited Liability Company 4665 NE 7th 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. 2023-12-11 Trinity Schroeder trinity@justlikenewdetails.com Des Moines Polk Iowa Jayson Jones Nikki Wilks Signed (1) The employer does not elect the employers’ liability coverage. Trinity Schroeder trinity@justlikenewdetails.com Member Des Moines Polk Iowa Jayson Jones Nikki Wilks 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
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
1412 2023-01-06 12:38 Anonymous (not verified) 72.255.93.91 Espindola Painting Services Proprietorship 4701 Woodland Ave Unit 3, West Des Moines, IA 50266 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-07 Hugo Espindola bmoellers@thebookeepersinc.net Des Moines Polk IA Jenny Espindola Gary Cort Signed (1) The employer does not elect the employers’ liability coverage. Brett Moellers bmoellers@thebookkeepersinc.net Accountant Des Moines Polk IA Jenny Espindola Gary Cort Signed
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
251 2020-09-08 17:00 Anonymous (not verified) 173.27.45.95 Peerless Construction, LLC Limited Liability Company 4718 E 49th Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-08 Grant Jipp grant.peerless@gmail.com Davenport Scott Iowa Dan Knight Bridget Knight Signed (1) The employer does not elect the employers’ liability coverage. Grant Jipp grant.peerless@gmail.com Owner Davenport Scott Iowa Dan Knight Bridget Knight Signed
1719 2023-07-01 21:34 Anonymous (not verified) 94.188.207.223 Granite & More Limited Liability Company 4730 Tremont ave Davenport Iowa 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-01 Hong Le granite732@yahoo.com Davenport Scott Iowa Jin Chen Betty Song Signed (1) The employer does not elect the employers’ liability coverage. Jin Chen clteam563@gmail.com Manager Bettendorf Scott Iowa Jin Chen Betty Song Signed
602 2021-08-13 22:49 Anonymous (not verified) 208.38.230.125 Granite & More Limited Liability Company 4730, Tremont Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-14 Jin Chen clteam563@gmail.com Davenport IA United States Jin Chen Betty Song Signed (1) The employer does not elect the employers’ liability coverage. Hong Le clteam563@gmail.com Self Davenport Scott Iowa Jin Chen Betty Song Signed
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
1745 2023-07-13 16:20 Anonymous (not verified) 94.188.205.174 Gaytan Framing LLC Limited Liability Company 4745 NE 27th Ct I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-13 Jose Gaytan Ruiz jose1988.jg8@gmail.com Des Moines Polk Des Moines Erwin Quintanilla Misael Balleza Signed (1) The employer does not elect the employers’ liability coverage. Jose Gaytan Ruiz jose1988.jg8@gmail.com Self Des Moines Polk Iowa Edwin Quintanilla Misael Balleza Signed
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
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
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
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
528 2021-05-21 14:06 Anonymous (not verified) 66.188.136.150 Russell Masartis Proprietorship 481 Clarendon East Dubuque, IL 61025 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-21 Russell Masartis kschumacher@tricorinsurance.com East Dubuque Jo Daviess IL Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Russell Masartis kschumacher@tricorinsurance.com Same East Dubuque Jo Daviess IL Mitch Kemp Shuree Behr Signed
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
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
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
217 2020-07-27 14:56 Anonymous (not verified) 72.2.163.232 Calvin Kroger Proprietorship 48232 292nd St. Hudson, SD 57034 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-27 Calvin Kroger calvinkroger@gmail.com Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed (1) The employer does not elect the employers’ liability coverage. Calvin Kroger calvinkroger@gmail.com proprietor Hudson Lincoln South Dakota Robin Anderson Adam Anderson Signed
1252 2022-08-12 13:11 Anonymous (not verified) 166.181.85.235 Cesar cardenas Proprietorship 48644 roma valley dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-06 Cesar Octavio Cardenas navarrete cesarcardenas981@gmail.com Des moines Polk Iowa Cesar cardenas navarrete Cesar cardenas Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Cesar cardenas cesarcardenas981@gmail.com Myself Des moines Polk Iowa Cesar cardenas Cesar cardenas gonzalez Signed
994 2022-03-22 12:19 Anonymous (not verified) 75.162.125.176 performance painting llc Limited Liability Company 4905 nw 4th street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-22 thomas lilly TLilly816@aol.com ankeny IOWA United States Sharon kay Gaulke Charles Thomas Cater Signed (1) The employer does not elect the employers’ liability coverage. Performance Painting LLC TLilly816@aol.com owner ankeny IOWA United States Sharon Kay Gaulke Charles Thomas Cater Signed
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
1833 2023-09-08 13:39 Anonymous (not verified) 94.188.207.225 Superior painting & epoxy coatings llc Limited Liability Company 4918 ne crestmoor ln I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-05 Anthony Negrete jr superior.paint@hotmail.com Ankeny IA United States Stacey Marie stoecker Anthony Negrete jr. Signed (1) The employer does not elect the employers’ liability coverage. Anthony Negrete jr superior.paint@hotmail.com Spouse Ankeny IA United States Anthony Negrete jr stacey marie Stoecker Signed
1553 2023-04-04 14:52 Anonymous (not verified) 94.188.205.177 TOPSOIL OUTDOOR SERVICES Limited Liability Company 4919 SCHUBERT ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-04-04 LIBAN topsoiloutdoor@gmail.com AMES IA United States Liban Wetzberger Liban Wertzberger Signed (1) The employer does not elect the employers’ liability coverage. Liban Wertzberger topsoiloutdoor@gmail.com Owner AMES IA United States Liban Wertzberger Liban Wertzberger Signed
1433 2023-01-27 13:24 Anonymous (not verified) 184.97.152.214 Rwdcarpet Proprietorship 4927 cedarbrook drive I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-01-27 Robert Wayne Durand iii rwdcarpet24@gmail.com Council bluffs Pottawattamie Iowa Kitty whissinand Kelley durand Signed (1) The employer does not elect the employers’ liability coverage. Robert Wayne Durand iii rwdcarpet24@gmail.com Self Council bluffs Pottawattamie Iowa Kitty whissinand Kelley Durand Signed
427 2021-03-10 11:52 Anonymous (not verified) 66.188.136.150 Ronald Tessen Proprietorship 493 Hill St. Green Lake, WI 54941 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-10 Ronald Tessen kschumacher@tricorinsurance.com Green Lake Green Lake WI Russell Masartis Amanda Seeberger Signed (1) The employer does not elect the employers’ liability coverage. Ronald Tessen kschumacher@tricorinsurance.com Same Green Lake Green Lake WI Russell Masartis Amanda Seeberger Signed
524 2021-05-17 22:41 Anonymous (not verified) 166.181.84.162 Laven Construction LLC Limited Liability Company 4935 NE 78th Ave Bondurant, Iowa 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-17 MacKale Laven maclaven@gmail.com Bondurant Polk Iowa John Smith Cameron Thede Signed (1) The employer does not elect the employers’ liability coverage. MacKale Laven maclaven@gmail.com Owner Bondurant Polk Iowa Cameron Thede John Smith Signed
1912 2023-11-16 08:40 Anonymous (not verified) 94.188.205.175 JC LANDSCAPING & LAWN CARE Proprietorship 4940 E. SHERIDAN AVE DES MOINES, IA 50317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-16 CLAUDIA TORO PINEDA CLAUDIAMEP@HOTMAIL.COM DES MOINES POLK IA BRENDA REEDY ADAM SMITH Signed (1) The employer does not elect the employers’ liability coverage. CLAUDIA TORO PINEDA CLAUDIAMEP@HOTMAIL.COM SELF DES MOINES POLK IA BRENDA REEDY ADAM SMITH Signed
1707 2023-06-25 10:39 Anonymous (not verified) 94.188.207.224 Michael D Ray Proprietorship 4944 Holcomb Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-22 Michael D Ray Jr mdray01@msn.com Des Moines Polk Iowa Bonnie R Finken Isaiah O Washington Signed (1) The employer does not elect the employers’ liability coverage. Michael D Ray mdray01@msn.com Owner Proprietor Des Moines Polk Iowa Bonnie R Finken Isaiah O Washington Signed
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
1904 2023-11-13 09:27 Anonymous (not verified) 94.188.207.224 Paul White Proprietorship 4991 Old C Boscobel, WI 53805 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-10 Paul White darrele@ciains.biz Boscobel Grant Wisconsin Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Paul White darrele@ciains.biz self Boscobel Grant Wisconsin Chris Fye Darrel Elsbernd Signed
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
1966 2023-12-27 13:17 Anonymous (not verified) 94.188.205.177 Jake Borntreger Proprietorship 50 Stone St Clermont, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-25 Jake Borntreger darrele@ciains.biz Clermont Fayette Iowa Chris Fye Darrel Elsbernd Signed (1) The employer does not elect the employers’ liability coverage. Jake Borntreger darrele@ciains.biz self Clermont Fayette Iowa Chris Fye Darrel Elsbernd Signed
319 2020-11-16 19:24 Anonymous (not verified) 173.30.37.132 Nathan Wright Proprietorship 500 2nd Avenue, Charles City, Iowa 50616 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-16 Nathan Robert Wright nrwright85@yahoo.com Charles City Floyd Iowa Jeff Wright Marsha Wright Signed (1) The employer does not elect the employers’ liability coverage. Nathan Robert Wright nrwright85@yahoo.com Self Charles City IA IA Jeff Wright Marsha Wright Signed
376 2021-01-26 11:14 Anonymous (not verified) 173.28.210.45 Cross Medical Lab, L.L.P Limited Liability Partnership 500 E Market St Iowa City IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-26 Aaron Klein lhavel_23@gmail.com Iowa City Johnson Iowa Ashley Lee Dan Wegman Signed (1) The employer does not elect the employers’ liability coverage. Lori Havel lhavel_23@gmail.com Office Manager Iowa CIty Johnson IA Ashley Lee Dan Wegman Signed
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
1079 2022-04-28 16:18 Anonymous (not verified) 3.217.29.203 John Paul Pokorny Proprietorship 500 W Adams St., Creston, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-04 John Paul Pokorny tylerins@tyleriowa.com Creston Union Iowa Jacquie Merritt Wendi Eslinger Signed (1) The employer does not elect the employers’ liability coverage. John Paul Pokorny tylerins@tyleriowa.com Owner Creston Union Iowa Jacquie Merritt Wendi Eslinger Signed
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
1408 2023-01-04 16:12 Anonymous (not verified) 50.82.188.217 Guerrero Masonry Proprietorship 5003 Keystone Rdg SE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-01 Jaime Guerrero jaime.guerrero@mchsi.com Cedar Rapids IA United States Susan Bender Larry Bender Signed (1) The employer does not elect the employers’ liability coverage. Jaime Guerrero jaime.guerrero@mchsi.com self CEDAR RAPIDS Linn Iowa Susan Bender Larry Bender Signed
1075 2022-04-28 07:53 Anonymous (not verified) 172.58.160.241 E & J Roofing LLC Limited Liability Company 5008 SE 5th Street Des Moines Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-28 E & J Roofing LLC janeylli2006@hotmail.com Des Moines United States Iowa Javier Solís Saldaña Arhely S. Saldaña Signed (1) The employer does not elect the employers’ liability coverage. E & J Roofing LLC janeylli2006@hotmail.com Owner Des Moines Polk Iowa Javier Solís Saldaña Arhely S. Saldaña Signed
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
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
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
2036 2024-02-07 16:22 Anonymous (not verified) 94.188.207.226 JR CONSTRUCTION Proprietorship 502 JOHNSON STREET, ALTA, IA 51002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 JOHAN PETERS REIMER reimerjohan16@gmail.com ALTA BUENA VISTA IOWA NEIL THIESSEN MARTENS PETER KLASSEN MARTENS Signed (1) The employer does not elect the employers’ liability coverage. JOHAN PETERS REIMER reimerjohan16@gmail.com SELF ALTA BUENA VISTA IOWA NEIL THIESSEN MARTENS PETER KLASSEN MARTENS Signed
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
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
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
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
1811 2023-08-21 17:03 Anonymous (not verified) 94.188.205.167 Cardinal Concrete LLC Limited Liability Company 503 17th St Boone, IA 50036 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-21 Ryan Woods cardinalconcrete.cw@gmail.com Boone Boone Iowa Jon Buller Terry Miles Signed (1) The employer does not elect the employers’ liability coverage. Ryan Woods cardinalconcrete.cw@gmail.com 100% owner Boone Boone Iowa Jon Buller Terry Miles Signed
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
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
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
361 2021-01-12 16:04 Anonymous (not verified) 50.82.130.211 Gregory Lievens Partnership 503 N. Main Street, Allison IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-12 Gregory Lievens cmins_re@mchsi.com Allison Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Gregory Lievens cmins_re@mchsi.com Self Allison Butler Iowa Chad Campbell Roxanne Kolder Signed
773 2021-11-24 14:48 Anonymous (not verified) 24.149.18.237 The Ragged Edge Art Bar and Gallery Limited Liability Company 504 Bluff Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-24 Kendra Wohlert kwohlert43@gmail.com CEDAR FALLS IA United States Theresa Johnson Danette Priebe Signed (1) The employer does not elect the employers’ liability coverage. Kendra Wohlert kwohlert43@gmail.com self CEDAR FALLS IA United States Theresa Johnson Danette Priebe Signed
135 2020-04-28 10:04 Anonymous (not verified) 74.84.101.138 W.A.D.E., Inc. DBA Decorah Cleaners Proprietorship 504 Heivly Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Darrin Walter chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed (1) The employer does not elect the employers’ liability coverage. Darrin Walter chelsea.whalen@upperiowains.com Owner Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed
136 2020-04-28 10:06 Anonymous (not verified) 74.84.101.138 W. A. D. E., Inc. DBA Decorah Cleaners Proprietorship 504 Heivly Street Decorah, IA 52101 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-23 Wanda Walter chelsea.whalen@upperiowains.com Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed (1) The employer does not elect the employers’ liability coverage. Wanda Walter chelsea.whalen@upperiowains.com Owner Decorah Winneshiek IA Robin C Schultz Chelsea Whalen Signed
1817 2023-08-24 12:29 Anonymous (not verified) 94.188.207.223 Global Roofing LLC Limited Liability Company 504 Heritage Rd Cedar Falls IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-20 Jose Rafael Delgado Marin grjrd808504@outlook.com Cedar Falls Black Hawk Iowa Noemi Guerrero Andres B Montoya Signed (1) The employer does not elect the employers’ liability coverage. Jose Rafael Delgado grjrd808504@outlook.com member Cedar Falls Black Hawk Iowa Noemi Guerrero Andres B Montoya Signed
1818 2023-08-25 15:16 Anonymous (not verified) 94.188.207.224 Global Roofing LLC Limited Liability Company 504 Heritage Rd Cedar Falls IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-20 Yenifer Yomara Hernandez Solis Grjrd808504@outlook.com Cedar Falls Black Hawk Iowa Noemi Guerrero Andres B Montoya Signed (1) The employer does not elect the employers’ liability coverage. Jose Rafael Delgado Marin Grjrd808504@outlook.com member Cedar Falls Black Hawk Iowa Noemi Guerrero Andres B Montoya Signed
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
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
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
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
1036 2022-04-06 10:22 Anonymous (not verified) 67.212.111.166 Precision Painting Proprietorship 507 Broad Street, Reinbeck Iowa 50669 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-06 Dan Bowser dbowser.precision.painting@gmail.com Reinbeck IA United States Kari Houle Steve Swanson Signed (1) The employer does not elect the employers’ liability coverage. Cory Koger coryspainting@gmail.com Self CEDAR FALLS IA United States Kari Houle Steve Swanson Signed
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
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
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
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
494 2021-04-22 12:41 Anonymous (not verified) 173.18.16.129 Unique Drywall Finishing LLC Limited Liability Company 509 E 26th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-22 jose angel chavez uniquewal@yahoo.com Des Moines Polk Iowa Lesa Reeves Jen Lambert Signed (1) The employer does not elect the employers’ liability coverage. Jose Angel Chavez uniquewal@yahoo.com owner Des Moines Polk Iowa Lesa Reeves Jen Lambert Signed
1949 2023-12-11 15:20 Anonymous (not verified) 94.188.207.223 Allens construction services llc Limited Liability Company 509 Nw Scott St Ankeny, Iowa 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-11 Allen Cheville acsllc515@gmail.com Ankeny Polk IOWA Allen Cheville Alexis Zimmerman Signed (1) The employer does not elect the employers’ liability coverage. Allen Cheville acsllc515@gmail.com Self Ankeny Polk IOWA Allen Cheville Alexis Zimmerman Signed
1777 2023-08-03 14:21 Anonymous (not verified) 94.188.207.227 Mark Doty Proprietorship 509 Parwood Circle, Huxley, IA 50124 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-03 Mark Doty mdoty@dakotagrown.com Huxley Story IA Rebecca R Moeller Jeffery F Vanasse Signed (1) The employer does not elect the employers’ liability coverage. Rebecca R Moeller Becky@northernlines.net Agent Fairmont MN United States Rebecca R Moeller Jeffery F Vanasse Signed
79 2020-02-25 17:28 Anonymous (not verified) 66.43.239.175 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-25 Tamara Glendenning lanceandabby@wccta.net Davis Junction Ogle Il Dena M. Anderson Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene IA Dena M Anderson Shelly Brus Signed
80 2020-02-25 17:29 Anonymous (not verified) 66.43.239.175 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-25 Terry Glendenning lanceandabby@wccta.net Davis Junction Ogle Il Dena M. Anderson Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene IA Dena M Anderson Shelly Brus Signed
81 2020-02-25 17:31 Anonymous (not verified) 66.43.239.175 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-25 Abby Glendenning lanceandabby@wccta.net Churdan Greene Iowa Dena M. Anderson Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene IA Dena M Anderson Shelly Brus Signed
82 2020-02-25 17:32 Anonymous (not verified) 66.43.239.175 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-25 Lance Glendenning lanceandabby@wccta.net Churdan Greene Iowa Dena M. Anderson Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Abby Glendenning lanceandabby@wccta.net Officer Churdan Greene IA Dena M Anderson Shelly Brus Signed
417 2021-03-03 13:49 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Lance Jeffrey Glendenning lanceandabby@wccta.net Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Abby Glendenning accounting@lynxag.com Officer Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
418 2021-03-03 13:50 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Abigail Jayne Glendenning lanceandabby@wccta.net Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Lance Jeffrey Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
419 2021-03-03 13:52 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Tamara Glendenning lanceandabby@wccta.net Davis Junction Ogle Illinois Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Lance Jeffrey Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
420 2021-03-03 13:53 Anonymous (not verified) 173.215.42.12 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-03-03 Terry Scott Glendenning lanceandabby@wccta.net Davis Junction Ogle Illinois Shelly L. Brus Dena M. Anderson Signed (1) The employer does not elect the employers’ liability coverage. Lance Jeffrey Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Shelly L. Brus Dena M. Anderson Signed
971 2022-03-14 17:59 Anonymous (not verified) 207.32.37.48 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan, IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-14 Lance Glendenning lanceandabby@wccta.net Churdan Greene Iowa Kim Kersey Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Abby Glendenning accounting@lynxag.com Officer Churdan Greene Iowa Kim Kersey Shelly Brus Signed
972 2022-03-14 18:01 Anonymous (not verified) 207.32.37.48 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan, IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-14 Abby Glendenning lanceandabby@wccta.net Churdan Greene Iowa Kim Kersey Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Kim Kersey Shelly Brus Signed
973 2022-03-14 18:02 Anonymous (not verified) 207.32.37.48 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan, IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-14 Terry Glendenning happysower4@gmail.com Davis Junction Ogle Illinois Kim Kersey Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Kim Kersey Shelly Brus Signed
974 2022-03-14 18:04 Anonymous (not verified) 207.32.37.48 Lynx Ag LLC Limited Liability Company 510 H Ave, Churdan, IA 50050 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-14 Tamara Glendenning happysower4@gmail.com Davis Junction Ogle Illinois Kim Kersey Shelly Brus Signed (1) The employer does not elect the employers’ liability coverage. Lance Glendenning lanceandabby@wccta.net President Churdan Greene Iowa Kim Kersey Shelly Brus Signed
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
937 2022-02-25 11:55 Anonymous (not verified) 174.242.226.43 K3 Recycling Limited Liability Company 510 West 2nd Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-25 Justin Kappelman justin@kappelmanappliance.com Indianola Iowa Iowa Kristy Kappelman Charles Kappelman Signed (1) The employer does not elect the employers’ liability coverage. Justin Kappelman justin@kappelmanappliance.com Same Indianola Iowa Iowa Kristy Kappelman Charles Kappelman Signed
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
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
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
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
207 2020-07-16 13:05 Anonymous (not verified) 173.16.140.254 Steve Kennedy Proprietorship 5108 SW 13th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-16 Steve Kennedy stevekennedy@gmail.com Des Moines Polk Iowa Jen Echterling Jake Hibbert Signed (1) The employer does not elect the employers’ liability coverage. Steve Kennedy stevekennedy007@gmail.com Owner Des Moines Polk Iowa Jen Echterling Jake Hibbert Signed
1324 2022-09-30 10:19 Anonymous (not verified) 172.86.18.249 Red Beard Buildings Limited Liability Company 511 16th St. Belle Plaine, IA 52208 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-30 Austin Carnes austin_carnes@hotmail.com Belle Plaine Benton IA Craig Roster Connor Doran Signed (1) The employer does not elect the employers’ liability coverage. Austin Carnes austin_carnes@hotmail.com President Belle Plaine Benton IA Craig Roster Connor Doran Signed
1653 2023-05-18 09:45 Anonymous (not verified) 94.188.205.166 Darwin Gonzales Rodriguez Proprietorship 511 5th Street NE Belmond IA 50421 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-10 Darwin Gonzales Rodriguez office.seamlesspros@icloud.com Belmond Wright Iowa Soila Perez Keith Clabaugh Signed (1) The employer does not elect the employers’ liability coverage. Darwin Gonzales Rodriguez office.seamlesspros@icloud.com Self Belmond Wright Iowa Soila Perez Keith Clabaugh Signed
379 2021-02-01 14:02 Anonymous (not verified) 166.181.84.117 Holker Construction LLC Limited Liability Company 512 n 15th st, Adel, ia 50003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-01 Justin Holker jjholker@gmail.com Adel Dallas Iowa Tyanna Holker Scot Baker Signed (1) The employer does not elect the employers’ liability coverage. Justin Holker jjholker@gmail.com Self Adel Dallas IA Tyanna Holker Scot Baker Signed
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
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
2180 2024-04-25 14:19 Anonymous (not verified) 94.188.205.169 Stems Flower Shop, LLC Limited Liability Company 515 8th St SE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-22 Stephanie Groom stephanie.groom@stemsiowa.com Altoona Polk Iowa Kelli Kerton Tyler Ingle Signed (1) The employer does not elect the employers’ liability coverage. Stephanie Groom stephanie.groom@stemsiowa.com Self - Business Owner Altoona Polk Iowa Kelli Kerton Tyler Ingle Signed
1927 2023-11-29 13:13 Anonymous (not verified) 94.188.207.228 Yaardman landscaping llc Limited Liability Company 51623 se seet cedar rapids iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-29 Adrian Pink Mr.Pink1118@gmail.com CEDAR RAPIDS IA United States Andrea Parker Kamar James Signed (1) The employer does not elect the employers’ liability coverage. Adrian Pink Mr.Pink1118@gmail.com Owner CEDAR RAPIDS IA United States Andrea Parker Kamar James Signed
1938 2023-12-05 11:54 Anonymous (not verified) 94.188.207.225 Genius automotive Limited Liability Company 51623 se seet cedar rapids iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-05 Adrian Pink Mr.Pink1118@gmail.com CEDAR RAPIDS IA United States Andrea Parker Kamar james Signed (1) The employer does not elect the employers’ liability coverage. Adrian Pink Mr.Pink1118@gmail.com None CEDAR RAPIDS IA United States Andrea Parker Kamar James Signed
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
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
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
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
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
405 2021-02-17 11:04 Anonymous (not verified) 104.201.67.178 CYE Painting Limited Liability Company 5202 SE 31st Ct Des Moines,IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-17 CYE Painting marilopez9657@yahoo.com Des Moines Polk Iowa Maricela Lopez Cruz Cabrera Signed (1) The employer does not elect the employers’ liability coverage. Maricela Lopez marilopez9657@yahoo.com N/a Des Moines Polk IA Maricela Lopez Cruz Cabrera Signed
304 2020-10-31 13:23 Anonymous (not verified) 173.17.230.149 Jerome Jones Proprietorship 5203 Douglas Avenue, Des Moines, IA 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-31 Jerome Jones jeromepops1@gmail.com Des Moines Polk IA Joe Simpson James Nelson Signed (1) The employer does not elect the employers’ liability coverage. Jerome Jones jeromepops1@gmail.com self Des Moines Polk IA Joe Simpson James Nelson Signed
1369 2022-11-11 13:02 Anonymous (not verified) 173.29.231.17 Salvador Cardenas Limited Liability Company 5206 SE 31st Street, Des Moines, Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-11 Salvador Cardenas salvadorcardenas16@icloud.com Des Moines Polk Iowa Omar Gonzalez Omar Gonzalez Signed (1) The employer does not elect the employers’ liability coverage. Salvador Cardenas salvadorcardenas16@icloud.com Owner Des Moines Polk Iowa Omar Gonzalez Omar Gonzalez Signed
719 2021-11-05 13:48 Anonymous (not verified) 174.198.66.202 James Johnson Ace Floor Guys Proprietorship 521 29th st NE Cedar Rapids, Ia 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-08-13 James Johnson acefloorguysia@gmail.com Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed (1) The employer does not elect the employers’ liability coverage. James Johnson acefloorguysia@gmail.com Self Employed Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed
151 2020-05-07 15:57 Anonymous (not verified) 198.167.182.164 Hawk-I Trucking LLC Limited Liability Company 521 Greenfield Dr, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-06 Chad Lee Freeman ricenogle@southslope.net Tiffin Johnson IA Scott Freeman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Chad Lee Freeman ricenogle@southslope.net Managing Member Tiffin Johnson IA Scott Freeman Dyan Kriener Signed
152 2020-05-11 15:56 Anonymous (not verified) 198.167.182.164 Hawk-I Trucking LLC Limited Liability Company 521 Greenfield Dr, Tiffin, IA 52340 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-11 Tyler Rogers tylerrogersinc@yahoo.com Iowa City Johnson Iowa Scott Freeman Dyan Kriener Signed (1) The employer does not elect the employers’ liability coverage. Tyler Rogers tylerrogersinc@yahoo.com Member Iowa City Johnson Iowa Scott Freeman Dyan Kriener Signed
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
1089 2022-05-05 15:49 Anonymous (not verified) 173.18.22.217 Dave Brecht Lawn Care Limited Liability Company 5213 SE 27th St Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-05 Dave Brecht Fagenmich@gmail.com Des Moines Polk IA Lesa Reeves Mitch Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Dave Brecht Fagenmich@gmail.com Owner Des Moines Polk IA Lesa Reeves Mitch Coluzzi Signed
501 2021-04-29 15:47 Anonymous (not verified) 184.179.6.93 Rodney Bohannon Proprietorship 5221 Crogans Way Rd, Council Bluffs IA 51501 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-29 Rodney Bohannon bohannonrod@gmail.com Council Bluffs POTTAWATTAMIE iowa KIMBERLY L ARFMAN Tami Cull Signed (1) The employer does not elect the employers’ liability coverage. Rodney Bohannon bohannonrod@gmail.com Owner Council Bluffs POTTAWATTAMIE IA KIMBERLY L ARFMAN Tami Cull Signed
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
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
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
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
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
1371 2022-11-14 10:55 Anonymous (not verified) 166.181.86.95 Dean Abramczak Proprietorship 524 Nodaway Dr center Point Iowa 52213 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-11-16 Dean Abramczak gabramczak@gmail.com Center Point IA United States Brenda Oconner Kenny McGraw Signed (1) The employer does not elect the employers’ liability coverage. Dean Abramczak gabramczak@gmail.com I am the only employee I own the company Center Point IA United States Brenda Oconnner Kenny McGraw Signed
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
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
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
886 2022-02-03 10:21 Anonymous (not verified) 217.180.228.144 Flo + Friends, LLC Limited Liability Company 52480 HWY 210 Slater, IA. 50244 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-03 Molly S Onken mollyaols@gmail.com Slater Story Iowa Pam Wilson Todd Wilson Signed (1) The employer does not elect the employers’ liability coverage. Molly S Onken mollyaols@gmail.com self slater Story Iowa Pam Wilson Todd Wilson Signed
1481 2023-02-24 12:45 Anonymous (not verified) 94.188.207.223 Molly Onken Limited Liability Company 52480 HWY 210 Slater, IA. 50244 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-20 Molly S Onken mollyaols@gmail.com Slater Story Iowa Pamela A Wilson Lori Konzen Signed (1) The employer does not elect the employers’ liability coverage. Molly S Onken mollyaols@gmail.com Owner Slater Story Iowa Pamela A Wilson Lori Konzen Signed
368 2021-01-21 15:12 Anonymous (not verified) 97.125.235.64 R. A. Snow Removals, Inc Proprietorship 525 7th St NW, Altoona, IA 50009 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-21 Robert Aaron Snow rasnowremovals.inc@gmail.com Altoona Polk Iowa Shannon Keely Moses Jessy James Dentler Signed (1) The employer does not elect the employers’ liability coverage. Robert Aaron Snow rasnowremovals.inc@gmail.com President Altoona IA United States Shannon Keely Moses Jessy James Dentler Signed
950 2022-03-04 19:58 Anonymous (not verified) 173.26.94.212 JRH Services Limited Liability Company 525 Third St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-04 Joshua Blakeslee jrhservicesiowa@outlook.com Evansdale Blackhawk IA Nicole Blakeslee Lois Riggleman Signed (1) The employer does not elect the employers’ liability coverage. Joshua Blakeslee jrhservicesiowa@outlook.com Owner Evansdale Blackhawk IA Nicole Blakeslee Lois Riggleman Signed
899 2022-02-05 13:35 Anonymous (not verified) 67.3.142.168 Hart Holland LLC Limited Liability Company 526 N 13th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-05 Elizabeth Holland ehollanddvm@gmail.com Adel IA IA Jon Hart Mary Hart Signed (1) The employer does not elect the employers’ liability coverage. Elizabeth Holland ehollanddvm@gmail.com self Adel IA IA Jon Hart Mary Hart Signed
900 2022-02-05 13:36 Anonymous (not verified) 67.3.142.168 Iconic Properties LLC Limited Liability Company 526 N 13th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-05 Elizabeth Holland ehollanddvm@gmail.com Adel IA IA Jon Hart Mary Hart Signed (1) The employer does not elect the employers’ liability coverage. Elizabeth Holland ehollanddvm@gmail.com self Adel IA IA Jon Hart Mary Hart Signed
2032 2024-02-07 11:05 Anonymous (not verified) 94.188.207.229 NEIL MARTENS Proprietorship 527 3RD STREET, SOUTH, ALBERT CITY, IA 50510 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-07 NEIL THIESSEN MARTENS pkmmartens@hotmail.com ALBERT CITY BUENA VISTA IOWA JOHN CLARENCE OLERICH ROBERT EUGENE BELT Signed (1) The employer does not elect the employers’ liability coverage. NEIL MARTENS pkmmartens@hotmail.com SELF ALBERT CITY BUENA VISTA IOWA JOHN CLARENCE OLERICH ROBERT EUGENE BELT Signed
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
578 2021-07-16 15:26 Anonymous (not verified) 184.80.177.137 Scotty's Appliance & TV, LLC Limited Liability Company 529 5th St NW - Dyersville, IA 52040 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-16 Sandra Krogman jheims@english-insurance.com Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed (1) The employer does not elect the employers’ liability coverage. Derrick Parsons jheims@english-insurance.com agent Dyersville Dubuque Iowa Joyce Heims Derrick Parsons Signed
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
1832 2023-09-08 12:01 Anonymous (not verified) 94.188.207.226 GFORCE Limited Liability Company 529 Anderson Street Jewell IA 50130 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-09-06 Scott Andrew Griffin G6@q.com Jewell Hamilton Iowa Colten Abram Griffin Hunter Austin Griffin Signed (1) The employer does not elect the employers’ liability coverage. Colten Abram Griffin G6@q.com Partner Ames Story Iowa Hunter Austin Griffin Scott Andrew Griffin Signed
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
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
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
1512 2023-03-10 09:44 Anonymous (not verified) 94.188.205.169 eliseo isai Proprietorship 5301 SE 24th St Des Moines, IA 50320 United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-08 eliseo isai carranza perez Misaelballeza40@gmail.com desmoines polk iowa Julio Nolvela giovanni nolvela Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. eliseo isai carranza perez Misaelballeza40@gmail.com self desmoines polk iowa Julio Nolvela giovanni nolvela Signed
2178 2024-04-25 10:56 Anonymous (not verified) 94.188.205.176 Loonpa Landscaping LLC Limited Liability Partnership 5309 Red Oak Ln Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-25 Daniel J White danny@barerootslawn.care Cedar Falls Black Hawk iowa Kari White James White Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Daniel J White danny@barerootslawn.care Owner Cedar Falls Black Hawk Iowa James White Kari White Signed
2179 2024-04-25 10:58 Anonymous (not verified) 94.188.205.177 Loonpa Landscaping LLC Limited Liability Partnership 5309 Red Oak Ln Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-25 Brent Barloon Brent@barerootslawn.care WAterloo Black Hawk Iowa James White Kari White Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Daniel White danny@barerootslawn.care Owner Cedar Falls Black Hawk Iowa James White Kari White Signed
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
390 2021-02-10 14:24 Anonymous (not verified) 173.24.190.134 King Excavation, LLC Limited Liability Company 5343 410th St, Cylinder IA 50528 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-03 Aletha King aletha1949@ncn.net Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed (1) The employer does not elect the employers’ liability coverage. Aletha King aletha1949@ncn.net Member of LLC Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed
391 2021-02-10 14:27 Anonymous (not verified) 173.24.190.134 King Excavation, LLC Limited Liability Company 5343 410th St, Cylinder IA 50528 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-02-03 Beth King aletha1949@ncn.net Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed (1) The employer does not elect the employers’ liability coverage. Beth King aletha1949@ncn.net Member of LLC Cylinder Palo Alto Iowa Candie Clark Dave Walters Signed
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
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
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
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
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
517 2021-05-12 15:08 Anonymous (not verified) 66.188.136.150 Lawrence D Todd Jr. Proprietorship 540 Sullivan St. Dubuque, IA 52001 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-05 Lawrence D Todd Jr. kschumacher@tricorinsurance.com Dubuque Dubuque IA Shuree Behr Jordan Bass Signed (1) The employer does not elect the employers’ liability coverage. Lawrence D Todd Jr. kschumacher@tricorinsurance.com Same Dubuque Dubuque IA Shuree Behr Jordan Bass Signed
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
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
988 2022-03-21 10:40 Anonymous (not verified) 173.27.156.183 JABS Construction/Finish Limited Liability Company 543 10th Ave. S. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-20 Roberto John Henrickson henricksonroberto10@gmail.com Clinton IA United States N/A N/a Signed (1) The employer does not elect the employers’ liability coverage. Roberto John Henrickson henricksonroberto10@gmail.com Owner Clinton IA United States N/A N/A Signed
989 2022-03-21 10:40 Anonymous (not verified) 173.27.156.183 JABS Construction/Finish Limited Liability Company 543 10th Ave. S. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-20 Roberto John Henrickson henricksonroberto10@gmail.com Clinton IA United States N/A N/a Signed (1) The employer does not elect the employers’ liability coverage. Roberto John Henrickson henricksonroberto10@gmail.com Owner Clinton IA United States N/A N/A Signed
1038 2022-04-11 09:43 Anonymous (not verified) 173.27.156.183 JABS Construction/Finish Limited Liability Company 543 10th Ave. S. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-11 Roberto John Henrickson henricksonroberto10@gmail.com Clinton IA United States Jordan Nisiewicz Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Jordan Nisiewicz jnisiewicz@leafhome.com Recruiter Kansas City Clay County Missouri Roberto J Henrickson Cody Dunbar Signed
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
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
619 2021-08-25 14:31 Anonymous (not verified) 192.154.15.2 MAV Restorations LLC Limited Liability Company 5461 Meadow Ct, Asbury, IA 52002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-25 Matthew Vaske mlvaske@gmail.com Asbury Dubuque IA Randi Taylor Carla Martin Signed (1) The employer does not elect the employers’ liability coverage. Matthew Vaske mlvaske@gmail.com Self Asbury Dubuque IA Randi Taylor Carla Martin Signed
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
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
320 2020-11-17 10:08 Anonymous (not verified) 65.103.82.36 Brian Behnkendorf dba Dutchmen Services Proprietorship 55 Rose Court West, Geneseo IL 61254 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-13 Brian Behnkendorf 4gbbehnk@gmail.com Geneseo Henry Illinois Kayla Artioli Eric Johnson Signed (1) The employer does not elect the employers’ liability coverage. Brian Behnkendorf 4gbbehnk@gmail.com Self Geneseo Henry Illinois Kayla Artioli Eric Johnson Signed
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
734 2021-11-11 14:05 Anonymous (not verified) 72.13.16.172 REDFEARN TRUCKING INC Proprietorship 5512 WEST STAGECOACH TRAIL I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-18 REDFEARN TRUCKING INC dave@allseasonstrucking.com GALENA JODAVIES IL DAVE NEUWOHNER BEN MOYER Signed (1) The employer does not elect the employers’ liability coverage. REDFEARN TRUCKING INC dave@allseasonstrucking.com PRESIDENT GALENA JODAVIES IL DAVE NEUWOHNER BEN MOYER Signed
1944 2023-12-06 16:41 Anonymous (not verified) 94.188.207.226 Sell Now Iowa Limited Liability Company 5525 Meredith Dr Suite B Des Moines, Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Sale Now Iowa team@sellnowiowa.com None Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
2072 2024-03-01 11:27 Anonymous (not verified) 94.188.207.226 SoldFast Real Estate L.L.C. Limited Liability Company 5525 Meredith Drive Des Moines, Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-02 Darlyn Fructuoso thejjscleaningllc@gmail.com Des Moines Polk IA Beatriz Musselman Darlyn Fructuoso Signed (1) The employer does not elect the employers’ liability coverage. Cody Wilkinson cody@soldfast.com Contractor Des Moine Polk IA Beatriz Musselman Darlyn Fructuoso Signed
1945 2023-12-06 16:47 Anonymous (not verified) 94.188.205.169 Sell Now Iowa Limited Liability Company 5525 Meredith Drive Suite B Des Moines Iowa 50310 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Alejandro Bacano Rodriguez alejandrobacanorodriguez@gmail.com Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed (1) The employer does not elect the employers’ liability coverage. Sell Now Iowa team@sellnowiowa.com None Des Moines Polk Iowa Breny Rodriguez Gabriela Martinez Signed
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
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
191 2020-06-23 16:09 Anonymous (not verified) 173.18.3.76 Look At You LLC Limited Liability Company 5545 Mills Civic Pkwy Ste 100 West Des Moines, IA 50265 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-23 Amber Keppler keppler_ark@outlook.com Des Moines Polk IA Angela Kinsey Jon Stetzel Signed (1) The employer does not elect the employers’ liability coverage. Amber Keppler keppler_ark@outlook.com LLC Member Des Moines Polk IA Angela Kinsey Jon Stetzel Signed
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
192 2020-06-24 07:42 Anonymous (not verified) 66.188.136.150 Paul Brickley Proprietorship 558 Franklin Ave. Galesburg, IL 61401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-23 Paul Brickley kschumacher@tricorinsurance.com Galesburg Knox IL Russell Masartis Nancy Wortley Signed (1) The employer does not elect the employers’ liability coverage. Paul Brickley kschumacher@tricorinsurance.com Same Galesburg Knox IL Russell Masartis Nancy Wortley Signed
1728 2023-07-08 10:48 Anonymous (not verified) 94.188.207.230 Lima Charlie LLC Limited Liability Company 56066 257th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-10 Larry Homan larry@Lima-Charlie.biz Glenwood Iowa United States Erin Jenkins Jeremy Jenkins Signed (1) The employer does not elect the employers’ liability coverage. Larry Lee Homan Larry@Lima-Charlie.biz Owner Glenwood Iowa United States Erin Homan Jeremy Jenkins Signed
1759 2023-07-26 07:09 Anonymous (not verified) 94.188.207.225 Lima Charlie LLC Limited Liability Company 56066 257th Street, Glenwood, IA 51534 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-26 Larry Joshua Homan Joshua@Lima-Charlie.biz Flatonia TX United States Leisha Kolb Troy Kolb Signed (1) The employer does not elect the employers’ liability coverage. Larry Joshua Homan Joshua@lima-charlie.biz Owner Flatonia Texas United States Leisha Kolb Troy Kolb Signed
1046 2022-04-14 08:11 Anonymous (not verified) 104.36.120.68 jet drywall Limited Liability Company 5611 westminster DR #5 cedarfalls IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 murion jones jetdrywall.construction@gmail.com cedarfalls black hawk iowa murion parely jones murion jones Signed (1) The employer does not elect the employers’ liability coverage. murion jones jetdrywal.construction@gmail.com owner cedarfalls black hawk iowa Murion Jones JR Eric Jones Signed
1047 2022-04-14 08:11 Anonymous (not verified) 104.36.120.68 jet drywall Limited Liability Company 5611 westminster DR #5 cedarfalls IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-14 murion jones jetdrywall.construction@gmail.com cedarfalls black hawk iowa murion parely jones murion jones Signed (1) The employer does not elect the employers’ liability coverage. murion jones jetdrywal.construction@gmail.com owner cedarfalls black hawk iowa Murion Jones JR Eric Jones Signed
183 2020-06-12 08:23 Anonymous (not verified) 107.77.173.7 A&W Marble & Tile Proprietorship 5624 Sw 5Th Pl I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-12 Wayne A Yergy wyergy@gmail.com Des Moines IA United States Michael L Smith Guy B Chaney Signed (1) The employer does not elect the employers’ liability coverage. Wayne Yergy wyergy@gmail.com Self Des Moines IA United States Michael L Smith Guy B Chaney Signed
1340 2022-10-18 17:03 Anonymous (not verified) 166.181.89.97 Stevens mobile welding services LLC Limited Liability Company 5645 se 56th st. Carlisle, IA 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-18 Daniel Robert Stephens dannystephens303@gmail.com Carlisle Polk Iowa Nikita Marie Knapp Stacy Robin Stephens Signed (1) The employer does not elect the employers’ liability coverage. Daniel Robert Stephens dannystephens303@gmail.com Owner Carlisle Polk Iowa Nikita Marie Knapp Stacy Robin Stephens Signed
618 2021-08-23 15:17 Anonymous (not verified) 173.17.131.91 Leaffilter North of Iowa, LLC Proprietorship 5650 NW Johnston IA 50131 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-23 Jorge Meraz jmaraz961@gmail.com 2906 e madison avenue Des moines IA Jisel chaves Melvin arevalo Signed (1) The employer does not elect the employers’ liability coverage. Jorge meraz jmeraz961@gmail.com Self Des moines Des moine IA Jusel chavez Melvin arevalo Signed
631 2021-09-02 22:46 Anonymous (not verified) 173.23.144.4 Lopez Framing LLC Limited Liability Company 566 walker st I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-02 Diana A Garcia Lopez lopezframing0702@gmail.com Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed (1) The employer does not elect the employers’ liability coverage. Diana A Garcia Lopez lopezframing0702@gmail.com Owner Des moines Polk Iowa Marlon Lopez Jennifer Reyes Signed
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
553 2021-07-01 08:17 Anonymous (not verified) 66.188.136.150 Cody Belleville Proprietorship 57167 Copperdate Dr. Elkhart, IN 46516 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-30 Cody Belleville kschumacher@tricorinsurance.com Elkhart Elkhart IN Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Cody Belleville kschumacher@tricorinsurance.com Same Elkhart Elkhart IN Mitch Kemp Shuree Behr Signed
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
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
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
1466 2023-02-17 15:12 Anonymous (not verified) 94.188.207.230 BIG Roofing, LLC Limited Liability Company 5751 NE 22nd St. #304 Des Moines, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-17 Tyler Jeffrey Baugh tj@bigroofing515.com Lincoln Lancaster Nebraska Steven Bieghler Andrew John Kohles Signed (1) The employer does not elect the employers’ liability coverage. Steven Craig Bieghler steve@bigroofing515.com Owner Cumming Dallas Iowa Tyler Jeffrey Baugh Andrew John Kohles Signed
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
1234 2022-08-01 16:55 Anonymous (not verified) 50.80.97.166 Joshua Schumacher Proprietorship 5801 timber creek rd ne I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-01 Josh Schumacher amjs2003@centurylink.net Cedar Rapids Iowa Iowa Karen Meroshek Philip McCurdy Signed (1) The employer does not elect the employers’ liability coverage. Josh Schumacher amjs2003@centurylink.net Self Cedar Rapids Iowa Iowa Katen Meroshek Philip McCurdy Signed
1858 2023-10-03 13:29 Anonymous (not verified) 94.188.207.223 Quad city drywall Solutions LLC Limited Liability Company 5804 n thornwood ave Davenport iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-03 Erivan Emmanuel Montalvo Delcompare montalvobills6@gmail.com Davenport Scott Iowa Natalia Ann Montalvo Juan Portela Signed (1) The employer does not elect the employers’ liability coverage. Erivan Emmanuel Montalvo Delcompare montalvobills6@gmail.com Owner Davenport Scott Iowa Natalia Montalvo Juan Portela Signed
154 2020-05-12 15:00 Anonymous (not verified) 97.125.253.184 Rundle Creations Limited Liability Company 5816 Urbandale Avenue, Des Moines, IA 50322 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-12 Mark Lavern Rundle II rundlecreations@gmail.com Des Moines Polk Iowa Luis Alex Jimenez Jennifer Lea Griffith Signed (1) The employer does not elect the employers’ liability coverage. Erika Anne Rundle rundlecreations@gmail.com Co-Owner Des Moines Polk Iowa Luis Alex Jimenez Jennifer Lea Griffith Signed
915 2022-02-15 16:43 Anonymous (not verified) 199.247.79.215 Dale B Wetherell Trucking Proprietorship 5844 40th Ave., Alta, IA 51002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-15 Dale Wetherell barbw@sppinsurance.com Alta Iowa Iowa Barbara Wetherell Kelli Turnquist Signed (1) The employer does not elect the employers’ liability coverage. Dale Wetherell barbw@sppinsurance.com Self Alta Buena Vista IA - Iowa Barb Wetherell Kelli Turnquist Signed
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
554 2021-07-01 15:54 Anonymous (not verified) 75.162.212.130 Avila Gutters Inc Proprietorship 5901 sw 5th st Des Moines IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-24 Enrique Avila enrique86avila@gmail.com Des moines polk iowa Yolanda Mendoza Lilliana Sanchez Signed (1) The employer does not elect the employers’ liability coverage. Enrique Avila enrique86Avila@gmail.com owner des moines polk iowa yolanda mendoza liliana sanchez Signed
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
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
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
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
839 2022-01-14 10:56 Anonymous (not verified) 173.29.218.216 Midwest Solar Services, LLC Limited Liability Company 595 Huff Street, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-01-10 Tyler Billmeyer tbillmeyer@midwestsolarservices.com Dubuque Dubuque Iowa Kim Esser Michelle Huss Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Midwest Solar Services, LLC kim.esser@kunkel-inc.com Insurance Agent Dubuque Dubuque Iowa Kim Esser Michelle Huss Signed
840 2022-01-14 10:58 Anonymous (not verified) 173.29.218.216 Midwest Solar Services, LLC Limited Liability Company 595 Huff Street, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-01-10 Matthew Shear mshear@midwestsolarservices.com Dubuque Dubuque Iowa Kim Esser Michelle Huss Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Midwest Solar Services, LLC kim.esser@kunkel-inc.com Insurance Agent Dubuque Dubuque Iowa Kim Esser Michelle Huss Signed
841 2022-01-14 15:23 Anonymous (not verified) 173.29.218.216 Midwest Solar Services, LLC Limited Liability Company 595 Huff Street, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-01-10 Matthew Shear mshear@midwestsolarservices.com Hanover Jo Daviess IL Kim Esser Michelle Huss Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Midwest Solar Services, LLC kim.esser@kunkel-inc.com Insurance Agent Dubuque Dubuque Iowa Kim Esser Michelle Huss Signed
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
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
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
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
684 2021-10-20 13:25 Anonymous (not verified) 65.144.174.26 A and H Home Improvement Limited Liability Company 600 NE 64th Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-20 Ivan A. Abel aandhhomeimprovement@gmail.com Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed (1) The employer does not elect the employers’ liability coverage. Ivan A. Abel aandhhomeimprovement@gmail.com Self Des Moines Polk Iowa Ken Krogman Bruce Baumgarn Signed
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
190 2020-06-19 11:08 Anonymous (not verified) 107.77.207.128 PAT Construction Limited Liability Company 6007 Sw 15th ST I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-06-21 Pablo Aguilar Tolentino PATConstruction77@gmail.com DES MOINES 77 77 Trisha Resendiz Toni Lopez Signed (1) The employer does not elect the employers’ liability coverage. Pablo Aguilar Tolentino PATconstruction77@gamil.com owner DES MOINES 77 77 Trisha Resendiz Toni Lopez Signed
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
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
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
961 2022-03-09 15:06 Anonymous (not verified) 207.199.231.172 Scott Ullrick Proprietorship 601 Grant St Beacon, IA 52534 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-09 Scott Ullrick scottullrick@msn.com Beacon Mahaska IA James Anderson Ashley Bryan Signed (1) The employer does not elect the employers’ liability coverage. Scott Ullrick scottullrick@msn.com Self Beacon Mahaska Iowa James Anderson Ashley Bryan Signed
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
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
269 2020-09-23 09:18 Anonymous (not verified) 76.76.239.60 belilove company of Iowa Inc Limited Liability Company 601 south 23rd street Fairfield Iowa 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-20 James Belilove jimb@cec-waterjet.com Fairfield Jefferson Iowa James thompson ellen bowen Signed (1) The employer does not elect the employers’ liability coverage. James Belilove jimb@cec-waterjet.com Owner and president Fairfield Jefferson Iowa James Thompson Ellen Bowen Signed
481 2021-04-14 17:15 Anonymous (not verified) 199.66.15.81 K3 Recycling Limited Liability Company 601 W. 1st Ave. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-14 JUSTIN KAPPELMAN justin@kappelmanappliance.com Indianola Iowa Iowa Kristy Kappelman Charlie Kappelman Signed (1) The employer does not elect the employers’ liability coverage. JUSTIN KAPPELMAN justin@kappelmanappliance.com Same person Indianola IA IA Kristy Kappelman Charlie Kappelman Signed
970 2022-03-14 14:08 Anonymous (not verified) 174.199.79.176 Friends Transportation Services LLC Limited Liability Company 6010 Creston Ave Unit 26, Des Moines, IA 50321 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-14 Mohammed Dood mohedali777@hotmail.com Des Moines Polk Iowa Leigh Laven Geoff Matlock Signed (1) The employer does not elect the employers’ liability coverage. Mohammed Dood mohedali777@hotmail.com Owner Des Moines Polk Iowa Leigh Laven Geoff Matlock Signed
521 2021-05-17 14:23 Anonymous (not verified) 66.188.136.150 Ron Wagner Proprietorship 602 1/2 Ave G Apt. 5 Ft. Madison, IA 52627 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-17 Ron Wagner kschumacher@tricorinsurance.com Ft. Madison Lee IA Jordan Bass Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. Ron Wagner kschumacher@tricorinsurance.com Same Ft. Madison Lee IA Jordan Bass Shuree Behr Signed
292 2020-10-27 18:15 Anonymous (not verified) 173.19.162.248 John Lass Limited Liability Company 6025 SE 16TH CT I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-27 John Lass johnwlass@gmail.com Des Moines IA United States Dawn Lass Gordon Lamp Jr. Signed (1) The employer does not elect the employers’ liability coverage. John Lass johnwlass@gmail.com self Des Moines IA United States Dawn Lass Gordon Lamp Jr Signed
998 2022-03-23 08:34 Anonymous (not verified) 104.201.100.158 L Peterson Insurance, LLC Limited Liability Company 603 Pleasant View Drive Des Moines, IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-23 Lucas Peterson lpeterson@phillipsstafford.com Des Moines Polk Iowa Luke Van Roekel Sam Debartolo Signed (1) The employer does not elect the employers’ liability coverage. Lucas Peterson lpeterson@phillipsstafford.com Owner Des Moines Polk Iowa Luke Van Roekel Sam Debartolo Signed
1595 2023-04-24 12:34 Anonymous (not verified) 94.188.205.166 Ankeny & Neighbors Proprietorship 603 South St, Cambridge Iowa 50046 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 William Richard Borchard III william@damageddevicerepair.com Cambridge Story Iowa Heather Borchard Mark Densmond Signed (1) The employer does not elect the employers’ liability coverage. William Borchard III william@damageddevicerepair.com Sole proprietor/owner Cambridge Story Iowa Heather Borchard Mark Densmore 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
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
227 2020-08-07 13:47 Anonymous (not verified) 173.28.28.57 Coffee Grounds, LLC dba Bev & Hennie's Limited Liability Company 604 Hwy 57, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-28 Missy Schellhorn cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Missy Schellhorn cmins_re@mchsi.com Self Aplington Butler Iowa Chad Campbell Roxanne Kolder Signed
228 2020-08-07 13:49 Anonymous (not verified) 173.28.28.57 Coffee Grounds, LLC dba Bev & Hennie's Limited Liability Company 604 Hwy 57, Parkersburg IA 50665 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-28 Kent Klooster cmins_re@mchsi.com Parkersburg Butler Iowa Chad Campbell Roxanne Kolder Signed (1) The employer does not elect the employers’ liability coverage. Kent Klooster cmins_re@mchsi.com Self Aplington Butler Iowa Chad Campbell Roxanne Kolder Signed
1988 2024-01-16 15:22 Anonymous (not verified) 94.188.205.176 Harmons Home Services LLC Limited Liability Company 605 w Cedar st, Cherokee, IA, 51012 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-16 Shawn Michael Harmon harmonsheatingandair@gmail.com Cherokee Ia United States Shawn Harmon Sara Harmon Signed (1) The employer does not elect the employers’ liability coverage. Shawn Michael Harmon Harmonsheatingandair@gmail.com Self Cherokee Cherokee IA Shawn Harmon Sara Harmon Signed
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
479 2021-04-14 14:58 Anonymous (not verified) 65.103.82.36 Aaron Smart Limited Liability Partnership 6064 227th st. albia IA 52531 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-01 Aaron Smart nonegiven@email.com Albia Monroe IA Emily Jordan Signed (1) The employer does not elect the employers’ liability coverage. Aaron Smart nonegiven@email.com partner Albia Monroe IA Emily Jordan Signed
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
1757 2023-07-20 14:45 Anonymous (not verified) 94.188.207.230 Lee Steffen Proprietorship 608 3rd Street NE, Farley, IA 52046 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-20 Lee Steffen lee.steffen22@icloud.com Farley Dubuque Iowa Derrick Parsons Joyce Heims Signed (1) The employer does not elect the employers’ liability coverage. Lee Steffen lee.steffen22@icloud.com Self Farley Dubuque Iowa Derrick Parsons Joyce Heims Signed
1888 2023-10-31 15:59 Anonymous (not verified) 94.188.207.225 CEM Businesses LLC Limited Liability Company 608 Evergreen Cir NW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-31 Ryan Canales ryancanales44@gmail.com West Des Moines Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
1886 2023-10-31 15:53 Anonymous (not verified) 94.188.205.176 CEM Businesses LLC Limited Liability Company 608 Evergreen Cir Nw Bondurant, IA 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-31 Dane McDonald dane.mcdonald@stellar-solar.net Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
1887 2023-10-31 15:57 Anonymous (not verified) 94.188.207.227 CEM BUSINESSES LLC Limited Liability Company 608 evergreen cir nw Bondurant, IA 50035 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-31 Dustin Rudolph dmrudo@gmail.com Des Moines Polk Iowa Raelynn Aicher Cameron VanBuren Signed (1) The employer does not elect the employers’ liability coverage. Dane McDonald dane.mcdonald@stellar-solar.net Self Bondurant Polk Iowa Raelynn Aicher Cameron VanBuren Signed
931 2022-02-21 15:04 Anonymous (not verified) 69.18.14.11 Lawn's Plus Proprietorship 6082 Northwest Beaver Drive, Johnston, Iowa 50131, United States I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-01 Javier Nieto jacobanderson55@yahoo.com Des Moines Polk Iowa Jacob Anderson Andrea Nieto Signed (1) The employer does not elect the employers’ liability coverage. Javier Nieto jacobanderson55@yahoo.com Self Des Moiens Polk Iowa Jacob Anderson Andrea Nieto Signed
634 2021-09-10 13:41 Anonymous (not verified) 173.23.145.231 julio medina Proprietorship 609 boyd st. des moines, iowa 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-10 julio medina medinajulio10001@gmail.com des moines polk iowa jose rivas Virginia Gomez Signed (1) The employer does not elect the employers’ liability coverage. Julio Medina medinajulio10001@gmail.com owner des moines polk iowa jose Rivas Virginia Gomez Signed
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
493 2021-04-22 08:54 Anonymous (not verified) 66.188.136.150 Frank Lantz Proprietorship 609 Clinton Street, Charles City, IA 50616 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-21 Frank Lentz kschumacher@tricorinsurance.com Charles City Floyd IA Shuree Behr Mitch Kemp Signed (1) The employer does not elect the employers’ liability coverage. Frank Lantz kschumacher@tricorinsurance.com Same Charles City Floyd IA Shuree Behr Mitch Kemp Signed
414 2021-02-28 15:32 Anonymous (not verified) 174.198.75.211 Charlie Christian Hutt Proprietorship 609 E. main St. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-29 Charlie Christian Hutt bmxican_04@hotmail.com Brooklyn poweshiek IA gene shafbough hannah hutt Signed (1) The employer does not elect the employers’ liability coverage. Charlie Christian Hutt bmxican_04@hotmail.com sole Brooklyn poweshiek IA gene shafbough hannah hutt Signed
466 2021-04-08 09:58 Anonymous (not verified) 216.81.153.249 Supreme Express Transport LLC Limited Liability Company 609 Euclid Ave, Cherokee, IA 51012 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-10 Liana Gil liana2702@gmail.com Cherokee Cherokee Iowa Leigh Laven Jared Brashears Signed (1) The employer does not elect the employers’ liability coverage. Liana Gill liana2702@gmail.com Owner Cherokee Cherokee Iowa Leigh Laven Jared Brashears Signed
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
1717 2023-06-29 11:42 Anonymous (not verified) 94.188.205.169 POWDER COATING CENTER Limited Liability Company 61 3RD ST NE HARTLEY IA 51346 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-28 MATT EMBREY MSEMBREY21@GMAIL.COM HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. MATT EMBREY MSEMBREY21@GMAIL.COM OWNER HARTLEY OBRIEN IOWA TAMI KLEIN JENNIFER YOUNGWIRTH Signed
1114 2022-05-17 15:30 Anonymous (not verified) 67.212.117.198 Busta Painting Limited Liability Company 610 W 26th st #1 Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-16 Evan Busta bustapainting@gmail.com Cedar Falls IA United States Tanner Heikens Garrett Burrack Signed (1) The employer does not elect the employers’ liability coverage. Evan Busta bustapainting@gmail.com Self Employeed Cedar Falls IA United States Tanner Heikens Garrett Burrack Signed
162 2020-05-19 15:03 Anonymous (not verified) 67.212.114.80 Collum Plumbing, LLC Limited Liability Company 610 West 20th Street, Cedar Falls, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-05-19 Stephen Collum collumplumbing@cfu.net Cedar Falls Iowa United States Mike Thode Linda Thode Signed (1) The employer does not elect the employers’ liability coverage. Stephen Collum collumplumbing@cfu.net Member of LLC Cedar Falls Black Hawk Iowa Mike Thode Linda Thode Signed
1657 2023-05-22 14:31 Anonymous (not verified) 94.188.207.224 Collum Plumbing, LLC Limited Liability Company 610 West 20th, Cedar Falls, IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-22 Stephen Collum collumplumbing@cfu.net Cedar Falls Iowa United States Mike Thode Linda Thode Signed (1) The employer does not elect the employers’ liability coverage. Stephen Collum collumplumbing@cfu.net Owner/Member of LLC Cedar Falls Black Hawk Iowa Mike Thode Linda Thode Signed
1244 2022-08-08 09:28 Anonymous (not verified) 174.255.1.240 Jose Rivera Proprietorship 6100 w lincoln way lot 25 Ames lA 50014 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-08 Jose Rivera josechepe91@icloud.com Ames Boone lowa Jose Rivera Jose Rivera Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Tim Tim@thefortress.net Friends Ames Boone Iowa Eliazar Martinez Sabino Díaz Signed
1245 2022-08-08 09:28 Anonymous (not verified) 174.255.1.240 Jose Rivera Proprietorship 6100 w lincoln way lot 25 Ames lA 50014 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-08-08 Jose Rivera josechepe91@icloud.com Ames Boone lowa Jose Rivera Jose Rivera Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Tim Tim@thefortress.net Friends Ames Boone Iowa Eliazar Martinez Sabino Díaz Signed
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
1942 2023-12-06 13:45 Anonymous (not verified) 94.188.207.228 K&K Service Limited Liability Company 6125 R57 Hwy Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-06 Keaton Klocko kklocko30@aim.com Indianola Warren Iowa Kourtne Klocko Mallory Metzger Signed (1) The employer does not elect the employers’ liability coverage. Keaton Klocko kklocko30@aim.com Owner Indianola Warren Iowa Kourtne Klocko Mallory Metzger Signed
1772 2023-08-01 15:09 Anonymous (not verified) 94.188.205.168 MHI Services Proprietorship 613 Damon St Council Bluffs, IA 51503 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-01 Lisa Mitchell lmitchell939@gmail.com Council Bluffs Pottawattamie Iowa Charles Meckna Christopher Young Signed (1) The employer does not elect the employers’ liability coverage. LIsa MItchellj lmitchell939@gmail.com Self Council Bluffs Pottawattamie Iowa Charles Meckna Christopher Young Signed
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
1936 2023-12-04 10:22 Anonymous (not verified) 94.188.205.174 Turkey River Ag Sales LLC Limited Liability Company 614 Vernon Rd. I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-04 David Ahern davidahern@turkeyriverag.com Cresco IOWA IOWA Michelle Ahern Alyse Ahern Signed (1) The employer does not elect the employers’ liability coverage. Turkey River Ag Sales LLC davidahern@turkeyriverag.com Owner Cresco Howard Iowa Michelle Ahern Alyse Ahern Signed
1342 2022-10-25 09:02 Anonymous (not verified) 174.240.251.79 Mahieu excavation Proprietorship 6140 n Lincoln ave Davenport iowa 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-10-25 Joshua j Mahieu ridinmytrain2@gmail.com Davenport Scott Iowa Mike Leon Joseph Koranda Signed (1) The employer does not elect the employers’ liability coverage. Joshua j Mahieu ridinmytrain2@gmail.com Owner Davenport Scott Iowa Mike Leon Joseph Koranda Signed
2213 2024-05-08 13:37 Anonymous (not verified) 94.188.205.174 Timothy strong Limited Liability Company 615 61street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-08 Timothy Dewayne strong jr timothystrong33@gmail.com Davenport iowa USA Iowa Thomasina hunter Tyletha dates Signed (1) The employer does not elect the employers’ liability coverage. Timothy strong painting timothystrong33@gmail.com Friend Davenport Usa Iowa Thomasina hunter Tyletha dates Signed
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
1321 2022-09-26 08:16 Anonymous (not verified) 204.141.215.159 Leaf filter Limited Liability Company 615 J Ave NE Cedar Rapids, Iowa I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-26 Dustin Hansen dhansen0925@gmail.com Marion Linn Iowa Audrianna Cleveland Trevor Frondle Signed (1) The employer does not elect the employers’ liability coverage. Leaf filter sewell@leafhome.com N/a Cedar rapids Linn Iowa N/a N/a Signed
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
1042 2022-04-12 10:10 Anonymous (not verified) 173.20.170.177 Yaseen Albayati Proprietorship 615 park st apt 1511 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Yaseen Albayati yaseenali53@gmail.com Des Moines Polk Iowa Alexis Bagas Bob Pankrukhin Signed (1) The employer does not elect the employers’ liability coverage. Yaseen Albayati yaseenali53@gmail.com self Des Moines polk Iowa Alexis Bagas Bob Pankrukhin Signed
1439 2023-02-06 11:00 Anonymous (not verified) 96.31.1.206 L&C LLC Limited Liability Company 615 W 6TH ST ESTHERVILLE, IA 51334 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-06 CARLOS MEDINA joel@walkerinsuranceia.com Estherville EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed (1) The employer does not elect the employers’ liability coverage. CARLOS MEDINA joel@walkerinsuranceia.com SELF Estherville EMMET IA JOSEPH THOMAS LORING JENNIFER JANET YOUNGWIRTH Signed
1533 2023-03-25 10:24 Anonymous (not verified) 94.188.207.226 Doug Uridil Proprietorship 616 16th Street NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-22 Doug Uridil douguridil@gmail.com Cedar Rapids United States IOWA Heidi Vincent Molly Coffman Signed (1) The employer does not elect the employers’ liability coverage. Doug Uridil douguridil@gmail.com Self Cedar Rapids United status IOWA Heidi Vincent Molly Kaufman Signed
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
574 2021-07-14 10:43 Anonymous (not verified) 173.27.17.202 Maxwell Taylor Proprietorship 618 east Colorado St. Davenport Iowa 52803 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-14 Maxwell Taylor maxwelltaylor33@icloud.com Davenport Scott Iowa Jacob Nagel Ty Reindl Signed (1) The employer does not elect the employers’ liability coverage. Maxwell Taylor maxwelltaylor33@icloud.com Self Davenport Scott Iowa Jacob Nagel Ty Reindl Signed
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
1289 2022-09-01 11:06 Anonymous (not verified) 104.222.95.52 Alliant Personnel Resources Limited Liability Company 619 N Carroll St, Carroll, IA 51401 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-09-01 Jonathan Sturm Jon@AlliantPR.com Carroll, IA Carroll County IA Sara Beiter Austin Scott Signed (1) The employer does not elect the employers’ liability coverage. Jon Sturm Jon@AlliantPR.com Owner Carroll, IA Carroll County Iowa Sara Beiter Austin Scott Signed
1385 2022-12-08 18:45 Anonymous (not verified) 173.26.84.6 Fansco LLC Limited Liability Company 620 2 nd Ave SE Cresco IOWA 52136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2022-12-08 Arif Sheikh Sheikha44@yahoo.com Cresco Howard IOWA Bibi Sheikh Usman Sheikh Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Arif Sheikh Sheikha44@yahoo.com Relative Henderson Clark Navada Bibi Sheikh Usman Sheikh Signed
1386 2022-12-09 08:35 Anonymous (not verified) 173.26.84.6 Fansco LLc DBA Cresco motel Limited Liability Company 620 2 nd Ave SE Cresco IOwa 52136 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-12-09 Arif Sheikh Sheikha44@yahoo.com Cresco Howard IOWA Bibi Sheikh Usman Sheikh Signed (1) The employer does not elect the employers’ liability coverage. Arif Sheikh Sheikha44@yahoo.com Self CRESCO Howard IOWA Bibi Sheikh Usman Sheikh Signed
1165 2022-06-23 09:28 Anonymous (not verified) 74.84.106.106 Rita Littrell Proprietorship 620 N. 9th St., Carlisle, Iowa 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 Rita Littrell ritaf1966@gmail.com Carlisle Warren Iowa Kimberly Owens Tina Owens Signed (1) The employer does not elect the employers’ liability coverage. Rita Littrell ritaf1966@gmail.com Self Carlisle Warren Iowa Kimberly Owens Tina Owens Signed
97 2020-03-21 12:05 Anonymous (not verified) 173.22.82.137 JHK Construction LLC Limited Liability Company 6203 Casey Court NE Cedar Rapids, IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-21 Edward Charles Loehr jhkconstruction10@gmail.com Cedar Rapids Linn County Iowa Brandon Peters Mandy Mason Signed (1) The employer does not elect the employers’ liability coverage. Edward Charles Loehr jhkconstruction10@gmail.com Owner 6203 Casey Court NE Linn County Iowa Brandon Peters Mandy Mason Signed
875 2022-01-31 11:00 Anonymous (not verified) 173.31.102.93 Jhk Construction LLC Limited Liability Company 6203 Casey Ct NE cedar Rapids Iowa 52411 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-31 Edward Charles Loehr jhkcostruction10@gmail.com Cedar Rapids Linn Iowa Leanne M Loehr Autumn G Loehr Signed (1) The employer does not elect the employers’ liability coverage. Jhk Construction LLC jhkconstruction10@gmail.com Owner Cedar Rapids Linn Iowa Leanne M Loehr Autumn G Loehr Signed
1729 2023-07-09 15:33 Anonymous (not verified) 94.188.207.223 Melvin A mineros Limited Liability Company 6209 Windsor dr des moines IA 50312 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-07-09 Melvin A mineros minerosframing.llc@gmail.com Des moines Polk IA Orlando dominguez Isaac salazar Signed (1) The employer does not elect the employers’ liability coverage. Jaime leiva jaime@boersmaninsurance.com Agent Des moines Polk IA Narciso hidalgo Balmore perez Signed
1778 2023-08-03 14:52 Anonymous (not verified) 94.188.207.227 Melvin A mineros Limited Liability Company 6209 Windsor dr des moines IA 50312 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2023-06-22 Melvin alexander mineros minerosframing.llc@gmail.com Des moines Polk IA Orlando dominguez Isaac salazar Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jaime leiva jaime@boersmaninsurance.com Agent Des moines Polk IA Narciso hidalgo Balmore perez Signed
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
2134 2024-04-04 08:10 Anonymous (not verified) 94.188.205.169 TERRA CONSTRUCTION LLC Limited Liability Company 621 Oak Park Ave Des Moines, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. 2024-04-04 Bryce Shabazz block.radio@yahoo.com Des Moines Polk Iowa Megan Donigan George Hana Signed (2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. Jessica L Heller Jessica.heller@adp.com Insurance Agent Allentown Lehigh PA Megan Donigan George Hana Signed
2052 2024-02-22 07:37 Anonymous (not verified) 94.188.207.229 Noahs Ark Flooring Proprietorship 6212 se 2nd st des moines iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-02-22 Noah James Daggett daggettnoah365@gmail.com Des moines Polk United States Malichi Cerrato Austin tolson Signed (1) The employer does not elect the employers’ liability coverage. Noah James Daggett daggettnoah365@gmail.com Self Des moines IA United States Malichi Cerrato Austin tolson Signed
2121 2024-03-28 00:05 Anonymous (not verified) 94.188.205.176 James bunting Limited Liability Company 6213 ridgewood meadows LN NE I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-03-28 James bunting jbflooringtile@gmail.com Cedar Rapids Linn Iowa Codee Marie Matt reynolds Signed (1) The employer does not elect the employers’ liability coverage. James bunting jbflooringtile@gmail.com Myself Cedar Rapids Linn Iowa Codee Marie Matt reynolds Signed
1134 2022-05-31 09:08 Anonymous (not verified) 65.125.92.130 EAC Multi-Services, Inc, Proprietorship 6224 Forest Ave. Des Moines, IA 50311 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-31 Alan E Enamordo enriqueecalowcare@gmail.com Des Moines Polk Iowa Chad Smith Adam Smith Signed (1) The employer does not elect the employers’ liability coverage. Alan E Enamordo enriqueecalowcare@gmail.com self Des Moines Polk IA Chad Smith Adam Smith Signed
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
722 2021-11-05 14:07 Anonymous (not verified) 209.252.172.87 Jeremiah Lunsford Proprietorship 624 Carroll Dr SE, Cedar Rapids, IA 52403 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-10 Jeremiah Lundsford jjaylunsford@gmail.com Cedar Paids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Jeremiah Lunsford jjaylunsford@gmail.com Self Employed Cedar Rapids Linn Iowa Sarah Coberley Heather Howell Signed
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
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
650 2021-09-22 20:46 Anonymous (not verified) 174.198.68.116 Freedom field services Limited Liability Company 6285 n 67 ave w baxter iowa 50028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-22 joseph robert cunningham jr joecunningham1966@protonmail.com Baxter IA United States chelsey a cunningham jordan r cunningham Signed (1) The employer does not elect the employers’ liability coverage. joseph robert cunningham jr joecunningham1966@protonmail.com owner Baxter IA United States chelsey a cunningham jordan r cunningham Signed
651 2021-09-22 21:05 Anonymous (not verified) 174.198.68.116 Freedom field services LLC Limited Liability Company 6285 n 67 ave w. BAXTER IOWA 50028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-09-22 joseph robert cunningham jr joecunningham1966@protonmail.com Baxter IA United States chelsey a cunningham jordan r cunningham Signed (1) The employer does not elect the employers’ liability coverage. joseph robert cunningham jr joecunningham1966@protonmail.com owner Baxter IA United States chelsey a cunningham jordan r cunningham Signed
595 2021-08-03 13:53 Anonymous (not verified) 174.248.224.252 Joseph r cunningham dba freedom field services Proprietorship 6285 n 67th ave w Baxter iowa 50028 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-03 Joseph r Cunningham jr. joecunningham1966@protonmail.com Baxter Jasper Iowa Chelsey Cunningham Chris Cort Signed (1) The employer does not elect the employers’ liability coverage. Joseph r cunningham jr joecunningham1966@protonmail.com Me Baxter Jasper Iowa Chelsey cunningham Chris cort Signed
1149 2022-06-09 17:43 Anonymous (not verified) 174.235.192.238 Bryan Linares Limited Liability Company 630 Hawthorne Ave I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-09 Bryan Linares bryan.linares7798@gmail.com Crete Saline Nebraska Bryan Linares Chris Linares Signed (1) The employer does not elect the employers’ liability coverage. Christopher Linares chris5linares1995@gmail.com Brother Crete Saline Nebraska Bryan Linares Chris Linares Signed
1628 2023-05-09 08:00 Anonymous (not verified) 94.188.205.175 Servin Drywall Proprietorship 6311 Underwood Ave SW, Cedar Rapids, IA 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-09 Arcel Servin arcelservin77@gmail.com Cedar Rapids Linn Iowa Rolandas Bitanas Kirk Strunk Signed (1) The employer does not elect the employers’ liability coverage. Arcel Servin arcelservin77@gmail.com Self Cedar Rapids Linn Iowa Rolandas Bitanas Kirk Strunk Signed
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
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
295 2020-10-28 15:19 Anonymous (not verified) 72.46.55.242 SAI'S RENTALS LLC Limited Liability Company 637 S ANKENY BLVD, ANKENY IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-28 SUMEET SEHGAL saisrentals.avisbudget@gmail.com ANKENY, IA POLK IOWA CLINT LILIENTHAL DIANNE KELLE Signed (1) The employer does not elect the employers’ liability coverage. SUMEET SEHGAL saisrentals.avisbudget@gmail.com SELF ANKENY POLK IOWA CLINT LILIENTHAL DIANNE KELLE Signed
1024 2022-04-01 09:25 Anonymous (not verified) 173.23.251.188 Norwalk Exterior Home Improvement Proprietorship 6391 Grimes St Indianola, IA 50125 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-01 John Lester norwalkexterior@gmail.com Indianola Warren Iowa Tara Murphy Mike Ryerson Signed (1) The employer does not elect the employers’ liability coverage. John Lester norwalkexterior@gmail.com owner Indianola Warren Iowa Tara Murphy Mike Ryerson Signed
222 2020-08-03 16:16 Anonymous (not verified) 204.98.109.114 Norval Craig Michael Proprietorship 640 NE 47th Place, Des Moines, IA 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-02-20 Norval Craig Michael accounts@dickersonmechanical.com Des Moines Polk Iowa Lisa Linnette Booher Kathryn Lou Dickerson Signed (1) The employer does not elect the employers’ liability coverage. Nornal Craig Michael accounts@dickersonmechanical.com Self Employeed - Sole Proprietor Des Moines Polk Iowa Lisa Linnette Booher Kathryn Lou Dickerson Signed
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
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
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
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
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
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
1981 2024-01-10 22:12 Anonymous (not verified) 94.188.205.175 Level Up Renovations LLC Limited Liability Company 648 31st Street, Des Moines, IA 50312 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-10 Luis Humberto Cazares Lopez leveluprenovationsia@outlook.com Des Moines Polk Iowa Gabriela Joanne Cazares Raquel Medina Signed (1) The employer does not elect the employers’ liability coverage. Luis Humberto Cazares Lopez leveluprenovationsia@outlook.com Owner Des Moines Polk Iowa Gabriela Joanne Cazares Raquel Medina Signed
210 2020-07-20 13:28 Anonymous (not verified) 75.162.95.97 RM construction Proprietorship 65 SE 5TH STREET APT 4 DES MOINES IA . 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-07-20 Rafael Marquez marquezrafael1@outlook.com Des Moines Polk IOWA IOWA Richard Yanez Francisco Garcia Signed (1) The employer does not elect the employers’ liability coverage. Rafael Marquez marquezrafael1@outlook.com owner Des Moines Polk IOWA Richard Yanez Francisco Garcia Signed
956 2022-03-08 13:56 Anonymous (not verified) 72.13.16.196 Naprstek Media LLC Limited Liability Company 6505 Wellington Ln, Dubuque, IA 52003 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-08 James Naprstek jimmy@kodiakcreative.com Dubuque Dubuque Iowa Trent Hanselmann Jonathan O'Brien Signed (1) The employer does not elect the employers’ liability coverage. Cheyenne Moseley services@e.legazoom.com Authorized Agent Glendale Los Angeles CA Trent Hanselmann Jonathan O'Brien Signed
1161 2022-06-22 19:41 Anonymous (not verified) 208.38.229.190 Samuel Perez Proprietorship 6523 N Main Street Davenport IA 52806 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-22 Samuel Perez samuelperez@live.com Davenport Scott Iowa Raven Perez Omar Sanchez Signed (1) The employer does not elect the employers’ liability coverage. Samuel Perez samuelperez@live.com Self Davenport Scott Iowa Raven Perez Omar Sanchez Signed
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
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
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
601 2021-08-12 16:37 Anonymous (not verified) 172.58.83.7 C & G Construction LLC Limited Liability Company 659 Sw Springfield Dr I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-12 Griselda Corona candgconst@gmail.com Ankeny Polk IA Clifton Kinney Marisol Chavira Signed (1) The employer does not elect the employers’ liability coverage. Juan Carlos corona candgconst@gmail.com Partner Ankeny Polk IA Clifton Kinney Marisol Chavira Signed
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
2129 2024-04-01 14:16 Anonymous (not verified) 94.188.207.227 Des Moines Construction LLC Limited Liability Company 6615 SE 3rd St Des Moines IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-01 Rodrigo Valdes desmoinesconstructionllc@gmail.com Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed (1) The employer does not elect the employers’ liability coverage. Rodrigo Valdes desmoinesconstructionllc@gmail.com Self Des Moines Polk Iowa Fabiola Palomares Nathan Miller Signed
760 2021-11-21 16:31 Anonymous (not verified) 107.77.206.216 Jacob Odean Limited Liability Company 6634 Lorton CT. Davenport IA 52807 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-11-21 Jacob James Odean jodean5725@gmail.com DAVENPORT IA United States James Odean Vickie Odean Signed (1) The employer does not elect the employers’ liability coverage. Jacob James Odean jodean5725@gmail.com Same DAVENPORT SCOTT United States James Odean Vickie Odean Signed
627 2021-08-31 16:12 Anonymous (not verified) 173.18.16.129 D's Home Improvement Limited Liability Company 665 27th St Des Moines IA 50312 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-08-31 Dustin Mitchell dustinmitchell8855@gmail.com Des Moines Polk Iowa Lesa Reeves Kelly Coluzzi Signed (1) The employer does not elect the employers’ liability coverage. Dustin Mitchell dustinmitchell8855@gmail.com Owner Des Moines Polk IA Lesa Reeves Kelly Coluzzi Signed
133 2020-04-27 21:56 Anonymous (not verified) 67.55.230.152 Hawkeye Carpentry LLC Limited Liability Company 665 Penn Ridge Drive 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. 2020-04-27 Travis Jaquay tjaquay@hotmail.com North Liberty Johnson Iowa Amber Butera Matt Butera Signed (1) The employer does not elect the employers’ liability coverage. Compass Commercial Services Bshanahan@compass-built.com subcontractor Hiawatha Linn Iowa Amber Butera Matt Butera Signed
1865 2023-10-09 10:28 Anonymous (not verified) 94.188.205.166 Lori Martinez Proprietorship 6650 SE 5 TH STREET DES MOINES IA, 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-10-09 Lori Martinez azulbenavidez04@gmail.com Des Moines Polk Iowa R. Mitch Coluzzi Jennifer Lambert Signed (1) The employer does not elect the employers’ liability coverage. Lori Martinez azulbenavidez04@gmail.com Self Des Moines Polk Iowa R. Mitch Coluzzi Jennifer Lambert Signed
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
256 2020-09-14 09:38 Anonymous (not verified) 66.188.136.150 Steven Headlee Proprietorship 671 Metaire Drive Apt. A, Greenwood, IN 46143 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-14 Steven Headlee kschumacher@tricorinsurance.com Greenwood Johnson IN Nancy Wortley Russell Masartis Signed (1) The employer does not elect the employers’ liability coverage. Steven Headlee kschumacher@tricorinsurance.com Same Greenwood Johnson IN Nancy Wortley Russell Masartis Signed
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
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
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
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
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
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
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
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
1285 2022-08-26 08:22 Anonymous (not verified) 97.125.43.203 Raul Villanueva Proprietorship 6901 SE 14th #71 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-24 Raul Villanueva deb@piciowa.com Des Moines Polk Iowa Debra Stratton Kelly Denger Signed (1) The employer does not elect the employers’ liability coverage. Raul Villanueva deb@picowa.com self Des Moines Polk IA Debra Stratton Kelly Denger Signed
1021 2022-03-30 11:20 Anonymous (not verified) 173.18.22.217 Arti Concrete Limited Liability Company 6901 SE 14th St Lot #226 Des Moines IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-30 Gerson David Artero arti.concrete31@gmail.com Des Moines Polk IA Lesa Reeves Erick Schuldt Signed (1) The employer does not elect the employers’ liability coverage. Gerson David Artero arti.concrete31@gmail.com Owner Des Moines Polk IA Lesa Reeves Erick Schuldt Signed
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
1268 2022-08-18 15:01 Anonymous (not verified) 75.162.65.221 Furgy's Carpet Limited Liability Company 6930 NE 56th St Lot 92, Altoona, IA 50009 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-18 Micheal Furgison furgy4f@gmail.com Altoona Polk Iowa Randy Lacina Laura Lacina Signed (1) The employer does not elect the employers’ liability coverage. Micheal Furgison furgy4f@gmail.com Self Altoona Polk Iowa Randy Lacina Laura Lacina Signed
1999 2024-01-25 16:57 Anonymous (not verified) 94.188.205.177 Nicholas Schaff Limited Liability Company 6934 rolling ridge ct sw cedar rapids Iowa 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-01-25 Nicholas Schaff schaff.lawncare@gmail.com cedar rapids linn iowa Brian Zeller Cassie Schaff Signed (1) The employer does not elect the employers’ liability coverage. Nicholas schaff schaff.lawncare@gmail.com Same person cedar rapids iowa iowa Brian zeller cassie schaff Signed
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
548 2021-06-24 22:08 Anonymous (not verified) 173.31.28.69 Brown's Window Cleaning +PLUS Proprietorship 700 11th Ave NW I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-24 Lawrence Brown brownswindowcleaningplus@gmail.com Altoona Iowa United States Jason Alderman Colette Evans Signed (1) The employer does not elect the employers’ liability coverage. Lawrence Brown brownswindowcleaningplus@gmail.com Self Altoona Iowa United States Jason Alderman Colette Evans Signed
793 2021-12-14 14:16 Anonymous (not verified) 174.22.96.99 Dubuque County Energy District Limited Liability Company 700 Locust Street, #195 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-10 Michaela Marie Freiburger michaela@energydistrict.org Dubuque Dubuque IA Diane Freiburger, Mother Michael Freiburger, Father Signed (1) The employer does not elect the employers’ liability coverage. Michaela Marie Freiburger michaela@energydistrict.org Contracted Vendor for the Dubuque County Energy District Dubuque Dubuque IA Diane Freiburger Michael Freiburger Signed
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
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
1495 2023-03-06 09:57 Anonymous (not verified) 94.188.207.224 Midwest Indoor Air Quality, LLC Limited Liability Company 701 NE Brook Haven Drive, Ankeny, IA 50021 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-06 Tanner Evan Francisco tanner.midwestindoorairquality@outlook.com Ankeny IA United States Sherry Reynolds David Boyer Signed (1) The employer does not elect the employers’ liability coverage. Midwest Indoor Air Quality, LLC tanner.midwestindoorairquality@outlook.com Same Ankeny IA United States Sherry Reynolds David Boyer Signed
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
1166 2022-06-23 09:44 Anonymous (not verified) 74.84.106.106 alan squires Proprietorship 702 2nd ave sw #4 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-23 alan squires shanesq411@gmail.comm altoona polk iowa TIna Owens Rita Littell Signed (1) The employer does not elect the employers’ liability coverage. alan squires shanesq411@gmail.com self altoona polk iowa Tina Owens Rita Littell Signed
487 2021-04-20 11:10 Anonymous (not verified) 207.191.193.167 Chento Construction Proprietorship 702 Lincoln St. Ainsworth, IA 52201 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-05 Alberto Garcia chentoconstruction@hotmail.com Ainsworth Washington Iowa Anthony Johnson Jessica Lopez Signed (1) The employer does not elect the employers’ liability coverage. Alberto Garcia chentoconstruction@hotmail.com Owner Ainsworth Washington Iowa Anthony Johnson Jessica Lopez Signed
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
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
30 2020-01-07 08:34 Anonymous (not verified) 199.10.5.7 Data Information Management LLC Limited Liability Company 703 Bluff St Dubuque IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-07 Stephen M Schauff steve@caricomm.com Dubuque Iowa IA Janet L Schauff Morris P Schauff Signed (1) The employer does not elect the employers’ liability coverage. Christopher R Broessel chris@caricomm.com Partner Dubuque Iowa IA Janet L Schauff Morris P schauff Signed
31 2020-01-07 08:37 Anonymous (not verified) 199.10.5.7 Data Information Management LLC Limited Liability Company 703 Bluff St Dubuque IA I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-01-07 Christopher R Broessel chris@caricomm.com Dubuque Dubuque IA Janet L Schauff Morris P Schauff Signed (1) The employer does not elect the employers’ liability coverage. Stephen M schauff steve@caricomm.com Partner Dubuque IA Dubuque Iowa Janet L schauff Morris P Schauff Signed
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
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
290 2020-10-23 15:13 Anonymous (not verified) 74.42.24.42 Gunter Trucking LLC Limited Liability Company 704 River Ave N., Belmond, IA 50421 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-10-23 Michael James Gunter mikegunter885@yahoo.com Belmond Wright Iowa Sondra Faye Godsell Lori Lynn Studer Signed (1) The employer does not elect the employers’ liability coverage. Michael James Gunter mikegunter885@yahoo.com Owner Belmond Wright Iowa Sondra Faye Godsell Lori Lynn Studer Signed
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
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
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
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
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
13 2019-12-30 14:27 Anonymous (not verified) 173.24.181.211 TERRY GALBRAITH DBA HUNEYDEW CONSTRUCTION Proprietorship 706 SUNSHINE RUN ARNOLDS PARK IA 51331 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2019-11-27 TERRY GALBRAITH CT_INSPECTIONS@MEDIACOMBB.NET ARNOLDS PARK DICKINSON IA KRIS WALKER JOE LORING Signed (1) The employer does not elect the employers’ liability coverage. TERRY GALBRAITH CT_INSPECTIONS@MEDIACOMBB.NET SELF ARNOLDS PARK DICKINSON IA JOE LORING KRIS WALKER 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
1267 2022-08-17 14:11 Anonymous (not verified) 174.192.75.162 Elijah wyant Proprietorship 708 1/2 w 3rd st davenport ia 52802 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-17 Elijah wyant Aidenwyant@gmail.com Davenport Scott Iowa Jake laxton Courtney sanders Signed (1) The employer does not elect the employers’ liability coverage. Elijah wyant Aidenwyant@gmail.com Self Davenport Scott Iowa Jake laxton Courtney sanders Signed
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
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
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
799 2021-12-15 11:48 Anonymous (not verified) 74.84.79.78 Juan Martinez Slazar Proprietorship 7085 Bloomfield Rd. Lot # 38 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-11-01 Juan A. Martinez Salazar juan50320@gmail.com Des Moines Polk Iowa Steve Young Logan Giudicessi Signed (1) The employer does not elect the employers’ liability coverage. Juan A. Martinez Salazar juan50320@gmail.com Owner Des Moines Polk Iowa Steve Young Logan Giudicessi Signed
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
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
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
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
1964 2023-12-22 10:19 Anonymous (not verified) 94.188.207.224 Dale Pahl Proprietorship 711 N. 1St. B105 Eldridge IA 52748 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-12-21 Dale Pahl Pada7910@gmail.com Eldridge Scott Iowa Samantha weston Rick mayerhofer Signed (1) The employer does not elect the employers’ liability coverage. Dale Pada7910@gmail.com Self Eldridge Scott IA Samantha weston Rick Mayerhofer Signed
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
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
894 2022-02-04 11:18 Anonymous (not verified) 152.117.105.90 Dusty schraceo Proprietorship 712 E 15th St Davenport, IA, 52803 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-04 Dusty Schraceo dustyschraceo1999@gmail.com Davenport Scott Iowa Tiffani Branham Cody Dunbar Signed (1) The employer does not elect the employers’ liability coverage. Dusty Schraceo dustyschraceo1999@gmail.com Self Davenport Scott Iowa Tiffani Branham Cody Dunbar Signed
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
874 2022-01-30 19:13 Anonymous (not verified) 199.168.106.132 Pete Wilcox Trenching Proprietorship 714 Main Street Cedar Falls IA 50613 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-29 Peter Wilcox kwilcox@cfu.net Cedar Falls Black Hawk Iowa Terri Strein Marlene Rasmussen Signed (1) The employer does not elect the employers’ liability coverage. The Accel Group LLC info@acceladvantage.com customer Cedar Falls Black Hawk IA Terri Strein Marlene Rasmussen Signed
2171 2024-04-22 14:09 Anonymous (not verified) 94.188.205.176 Messer's concrete cutting Proprietorship 714 Summer Street I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-04-22 Joe messer josephdmesser@gmail.com Burlington IA United States Joe messer Joe messer Signed (1) The employer does not elect the employers’ liability coverage. Joe messer josephdmesser@gmail.com Owner Burlington IA United States Joe messer Joe messer Signed
1239 2022-08-02 10:53 Anonymous (not verified) 184.80.177.137 Jamie Ingle, DBA Jamie's Little Sunflowers Proprietorship 7155 Columbus St - New Vienna, IA 52065 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-08-02 Jamie Ingle jheims@english-insurance.com Dyersville Dubuque IA Derrick Parsons Joyce Heims Signed (1) The employer does not elect the employers’ liability coverage. Derrick Parsons dparsons@english-insurance.com self Dyersville Dubuque Iowa Derrick Parsons Joyce Heims Signed
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
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
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
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
1843 2023-09-14 14:12 Anonymous (not verified) 94.188.205.167 Rosenbum Construction, LLC Limited Liability Company 720 South Street, Arlington, Iowa 50606 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 Thomas Rosenbum tomdolly1126@yahoo.com Arlington Fayette Iowa Dolly Rosenbum Steve Frost Signed (1) The employer does not elect the employers’ liability coverage. Thomas Rosenbum tomdolly1126@yahoo.com Self Arlington Fayette Iowa Dolly Rosenbum Steve Frost Signed
953 2022-03-07 16:13 Anonymous (not verified) 173.27.196.168 Joel Cisneros Proprietorship 721 e madison ave Des Moines Iowa 50313 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-03-07 Joel Cisneros cisnerostile476@gmail.com Des monies Polk county Iowa Aurora Cisneros Romualda Ramos Signed (1) The employer does not elect the employers’ liability coverage. Joel Cisneros cisnerostile476@gmail.com Employee Des Moines Polk Iowa Aurora Cisneros Romualda Ramos Signed
1804 2023-08-16 18:22 Anonymous (not verified) 94.188.207.226 Zach Moyle Masonry Limited Liability Company 7222 Great 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. (1) I am not electing the employers’ liability coverage. 2023-08-16 Zach Moyle zmoylemasonry@gmail.com Clermont FAYETTE FAYETTE Brittney Loyd Dave Moyle Signed (1) The employer does not elect the employers’ liability coverage. Zach Moyle zmoylemasonry@gmail.com Self Clermont FAYETTE FAYETTE Brittney Loyd Dave Moyle 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
2214 2024-05-08 13:49 Anonymous (not verified) 94.188.205.168 Hagen Installation Solutions LLC Limited Liability Company 725 Cole St Carlisle, IA 50047 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-08 Clay Allen Hagen clay.hagenson@gmail.com Carlisle Warren Iowa Tyler Bumgardner Spencer Kissinger Signed (1) The employer does not elect the employers’ liability coverage. Clay Allen Hagen clay.hagenson@gmail.com Same person Carlisle Warren Iowa Tyler Bumgardner Spencer Kissinger Signed
582 2021-07-22 15:14 Anonymous (not verified) 173.24.111.218 Joseph Davis Proprietorship 7257 Valley Dr, bettendorf ia 52722 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-07-22 Joseph Davis jtigerd@live.com Bettendorf Scott IA Jacob nagel Nick brewer Signed (1) The employer does not elect the employers’ liability coverage. Joseph Davis jtigerd@live.com Agent Bettendorf IA IA Jacob nagel Nick brewer Signed
460 2021-04-05 15:24 Anonymous (not verified) 173.20.169.155 Tim Stiles Proprietorship 726 Grant St PO box 217 Dexter Iowa 50070 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-04-04 Tim Stiles timcolleenstiles@gmail.com Dexter Dallas Iowa Karen Penton ERIC TIERNAN Signed (1) The employer does not elect the employers’ liability coverage. Tim Stiles timcolleenstiles@gmail.com Same Tim Stiles Dexter Dallas Iowa Karen Penton Eric Tiernan 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
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
1437 2023-02-01 15:42 Anonymous (not verified) 174.215.242.112 Safe step walk in tub of Minnesota Limited Liability Company 7300 Washington Ave S. Eden prairie, MN 55344 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-02-01 Edward Koch etkdbq@aol.com Waterloo IA United States Glenda mclarty Coen Koch Signed (1) The employer does not elect the employers’ liability coverage. James alley JAlley@safesteptub.com Vice president of production Eden prairie Hennepin MN Brent Jarvis Bruce illies Signed
2217 2024-05-09 14:28 Anonymous (not verified) 94.188.207.224 Emmanual A Sanchez Chavez Proprietorship 7301 Fleur Dr, Lot 10, Des Moines, IA 50325 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2024-05-09 Emmanuel A Sanchez Chaves alexsanchw3@gmail.com Des Moines Polk Iowa Jesus Garcia Fabion Dalgato Signed (1) The employer does not elect the employers’ liability coverage. Emmanuel A Sanchez Chavez alexsanchw3@gmail.com Person Des Moines Polk Iowa Jesus Garcia Fabion Dalgato Signed
701 2021-10-29 18:35 Anonymous (not verified) 173.18.85.215 Saunders Construction Proprietorship 7304 SW 14th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-29 Charles Saunders charlessaunders901@gmail.com Des Moines Iowa Iowa Ramona Mitchell Rasheedah Gasaway Signed (1) The employer does not elect the employers’ liability coverage. Charles Saunders charlessaunders901@gmail.com Owner Des Moines IA United States Ramona Mitchell Rasheedah Gasaway Signed
696 2021-10-28 10:33 Anonymous (not verified) 173.18.85.215 Saunders Construction Proprietorship 7304 SW 14th St Des Moines Iowa 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-10-28 Charles A Saunders charlessaunders901@gmail.com Des Moines IA United States Ramona Mitchell Rasheedah Gasaway Signed (1) The employer does not elect the employers’ liability coverage. Charles Saunders charlessaunders901@gmail.com Owner Des Moines Polk Iowa Ramona Mitchell Rasheedah Gasaway Signed
1785 2023-08-06 17:37 Anonymous (not verified) 94.188.207.225 J and B Zuck Trucking LLC Limited Liability Company 7310 E Airline Hwy Dunkerton, IA 50626 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-08-08 Justin Zuck jandbzucktrucking@gmail.com DUNKERTON Iowa United States Justin Zuck Rebekah Zuck Signed (1) The employer does not elect the employers’ liability coverage. Justin Zuck jandbzucktrucking@gmail.com owner DUNKERTON Iowa United States Justin Zuck Rebekah Zuck Signed
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
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
1172 2022-06-27 14:42 Anonymous (not verified) 162.253.44.28 Hardwood Design Co Limited Liability Company 75 Commercial Drive North Liberty Iowa 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-17 Tyler Fisher hardwooddesignllc@gmail.com Coralville Johnson Iowa Joan Tobin Olivia Meier Signed (1) The employer does not elect the employers’ liability coverage. Tyler Fisher hardwooddesignllc@gmail.com self Coralville Johnson Iowa Joan Tobin Olivia Meier Signed
1173 2022-06-27 14:44 Anonymous (not verified) 162.253.44.28 Hardwood Design Co LLC Limited Liability Company 75 Commercial Drive North Liberty Iowa 52317 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-17 Rilen Carew hardwooddesignllc@gmail.com Coralville Johnson Iowa Joan Tobin Olivia Meier Signed (1) The employer does not elect the employers’ liability coverage. Tyler Fisher hardwooddesignllc@gmail.com other member of LLC Coralville Johnson Iowa Joan Tobin Olivia Meier Signed
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
1632 2023-05-09 11:10 Anonymous (not verified) 94.188.205.177 MM Drywall LLC Moises Melo Santiago Proprietorship 7500 Bloomfield Road Lot 78 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-03-01 Moises Melo Santiago deb@piciowa.com Des Moines Polk Iowa kelly Denger Debra Stratton Signed (1) The employer does not elect the employers’ liability coverage. MM Drywall LLC Moises Melo Santiago deb@piciowa.com self Des Moines polk Iowa Kelly Denger Debra Stratton Signed
552 2021-06-29 14:55 Anonymous (not verified) 97.125.35.240 Melo Drywall Proprietorship 7500 Bloomfield Road Lot 78 Des Moines, Iowa 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-25 Marlene Bautista bbautistamarbb@gmail.com Des Moines Polk Iowa Brian Pruitt Kelly Denger Signed (1) The employer does not elect the employers’ liability coverage. Marlene Bautista bbautistamarbb@gmail.com self Des Moines Polk Iowa Brian Pruitt Kelly Denger Signed
725 2021-11-05 14:32 Anonymous (not verified) 174.198.66.202 Jay Schulte Proprietorship 7530 Prairie Hawk Dr Sw, Cedar Rapids, Ia 52404 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-09-15 Jay Schulte schultejay@Hotmail.com Cedar Rapids Linn Iowa Heather Howell Sarah Coberley Signed (1) The employer does not elect the employers’ liability coverage. Jay Schulte schultejay@hotmail.com Self Employed Cedar Rapids Linn Ia Sarah Coberley Heather Howell Signed
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
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
1637 2023-05-10 15:39 Anonymous (not verified) 94.188.207.230 Carly Roskop Proprietorship 7706 Hampshire Ct NE Cedar Rapids, IA 52402 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-05-10 Carly Roskop carlyroskop@gmail.com Cedar Rapids IA United States Dustin Roskop Tracy Petrak Signed (1) The employer does not elect the employers’ liability coverage. Carly Roskop carlyroskop@gmail.com Self Cedar Rapids IA United States Dustin Roskop Tracy Petrak Signed
103 2020-03-25 11:48 Anonymous (not verified) 174.250.52.2 ReFormin' Homes Proprietorship 7740 NW 16th Street, Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-25 Martin Samuel Ledy reforminhomes@gmail.com Ankeny Iowa United States Timothy Allen Raynard Nicholas Paul Curtis Signed (1) The employer does not elect the employers’ liability coverage. Martin Samuel Ledy reforminhomes@gmail.com Same Person Ankeny Iowa United States Timothy Allen Raynard Nicholas Paul Curtis Signed
1688 2023-06-13 09:29 Anonymous (not verified) 94.188.207.228 Ron Burbach Proprietorship 7760 commerce park Dubuque Iowa 52002 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-06-13 Ronald V Burbach allgreenron@msn.com Dubuque Dubuqie Iowa Mia Burnach Jerry david Signed (1) The employer does not elect the employers’ liability coverage. Ronald V Burbach allgreenron@man.com Same Dubuque Dubuque Iowa Mia F Burbach Jerry David Signed
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
522 2021-05-17 20:27 Anonymous (not verified) 50.81.4.25 Crew Cut Lawn Care Limited Liability Company 7820 1st Ave NW Cedar Rapids, IA 52405 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-05-17 Rupert McKendly Ellis wideglide94@gmail.com Cedar Rapids Linn Iowa Adrian Pink Lorraine Ellis Signed (1) The employer does not elect the employers’ liability coverage. Rupert M Ellis wideglide94@gmail.com Owner Cedar Rapids Linn IA Adrian Pink Lorraine Signed
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
119 2020-04-14 14:38 Anonymous (not verified) 66.188.136.150 Matthew Popejoy Proprietorship 7897 21st Ave., Blaristown, IA 52209 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-04-14 Matthew Popejoy popejoymatthew@gmail.com Blairstown Benton IA Russell Masartis Cody McClain Signed (1) The employer does not elect the employers’ liability coverage. Dan Oberfoell doberfoell@tricorinsurance.com Agent Blairstown Benton IA Russell Masartis Cody McClain Signed
1056 2022-04-18 12:04 Anonymous (not verified) 63.152.56.49 Milo’s Construction Limited Liability Company 8 Erobi ln Iowa city IA 52240 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-18 Adriana Celis celisary0501@gmail.com Iowa city Johnson Iowa Arcelia Gómez Karina Beltrán Signed (1) The employer does not elect the employers’ liability coverage. Milo’s Construction celisary0501@gmail.com Owner Iowa city Johnson Iowa Arcelia Gómez Karina Beltrán Signed
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
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
1030 2022-04-05 06:27 Anonymous (not verified) 172.58.86.173 MR Roofing LLC Limited Liability Company 8012 Ashridge Rd. Fort Worth, Tx 76134 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-05 MR Roofing LLC mrroofing.pr@gmail.com Fort Worth Tarrant Texas Juan M. Robledo Jose A. Robledo Signed (1) The employer does not elect the employers’ liability coverage. Paul Robledo mrroofing.pr@gmail.com Owner Fort Worth Tarrant Texas Juan M. Robledo Jose A. Robledo Signed
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
1070 2022-04-26 09:35 Anonymous (not verified) 174.198.72.171 Boyz Roofing LLC Limited Liability Company 802 E County Lane Rd Lot 25 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-26 Cupertino Rodriguez Hernandez christopherrodriguez091889@gmail.com Des Moines Polk Iowa Yoselin Morales Manny Sokop Signed (1) The employer does not elect the employers’ liability coverage. Cupertino Rodriguez Hernandez christopherrodriguez091889@gmail.com Owner Des Moines Polk Iowa Yoselin Morales Manny Sokop Signed
1917 2023-11-21 12:40 Anonymous (not verified) 94.188.205.174 Ramos Painting LLC Limited Liability Company 802 E COUNTY LINE RD #279, Des Moines, IA 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2023-11-01 Pedro Ramos gcort06@gmail.com Des Moines Polk Iowa Leonel Ramos Jose Ramos Signed (1) The employer does not elect the employers’ liability coverage. Pedro Ramos gcort06@gmail.com Owner Des Moines Polk Iowa Leonel Ramos Jose Ramos Signed
1069 2022-04-26 08:39 Anonymous (not verified) 174.198.72.171 GR Roofing Proprietorship 802 E County Line Rd Lot 137, Des Moines, Ia 50320 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-04-26 Eleazar Guzman-Rios emmanuelgscop.1425@gmail.com Des Moines Polk Iowa Manny Socop Julio Andrew Signed (1) The employer does not elect the employers’ liability coverage. Eleazar Guzman-Rios emmanuelgscop.1425@gmail.com Owner Des Moines Polk Iowa Manny Socop Julio Andrews Signed
366 2021-01-18 18:32 Anonymous (not verified) 75.162.57.214 Affordable Exteriors, LLC Limited Liability Company 802 east COUNTY LINE RD #57 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-01-18 Destiny Moses Info@mktdsm.com DES MOINES IA United States Miguel Angel Garcia Ramirez Nelly Bekker Signed (1) The employer does not elect the employers’ liability coverage. Destiny Moses Info@mktdsm.com owner DES MOINES IA United States Miguel Garcia Nellie Bekker Signed
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
1141 2022-06-03 08:15 Anonymous (not verified) 173.23.251.188 SP Exteriors, LLC Limited Liability Company 804 Philip St Des Moines, IA 50315 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-03 Travis Espey tespey48@gmail.com Des Moines Polk IA Tara Murphy Mike Ryerson Signed (1) The employer does not elect the employers’ liability coverage. Travis Espey tespey48@gmail.com owner Des Moines Polk IA Tara Murphy Mike Ryerson Signed
906 2022-02-09 08:57 Anonymous (not verified) 173.28.0.37 CAB Holdings LLC Limited Liability Company 804 SE Cherry ST Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-09 Kristy Briles kristyabriles@gmail.com Des Moines Polk IA Stephanie Seymour Sue Briles Signed (1) The employer does not elect the employers’ liability coverage. Kristy Briles kristyabriles@gmail.com owner Des Moines Polk IOwa Stephanie Seymour Sue Briles Signed
907 2022-02-09 08:59 Anonymous (not verified) 173.28.0.37 Rusty K5 LLC Limited Liability Company 804 SW Cherry St Ankeny, IA 50023 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-02-09 Kristy Briles kristyabriles@gmail.com Des Moines Polk IA Stephanie Seymour Sue Briles Signed (1) The employer does not elect the employers’ liability coverage. Kristy Briles kristyabriles@gmail.com Owner Des moines Polk IA 50313 Sue Briles Signed
1084 2022-05-02 15:23 Anonymous (not verified) 173.23.196.11 Sweet Green Arborist Services, LLC Limited Liability Company 804 W. Briggs Ave, Fairfield, IA 52556 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-05-02 Andrew Forest Nash sweetgreenarborist@gmail.com Fairfield Jeffereson Iowa Eli Morgan Rachel Morgan Signed (1) The employer does not elect the employers’ liability coverage. Andrew Nash anash66@gmail.com same Fairfield Jeffereson Iowa Rachel Morgan Eli Morgan Signed
794 2021-12-14 14:18 Anonymous (not verified) 65.144.174.26 iDesign Limited Liability Company 805 15th St, Dallas Center, IA 50063 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-12-14 Michelle Wiedman idesigninside@gmail.com Dallas Center Dallas IA Carl Sprague Neal Bunn Signed (1) The employer does not elect the employers’ liability coverage. Michelle Wiedman idesigninside@gmail.com Self Dallas Center Dallas Iowa Carl Sprague Neal Bunn Signed
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
105 2020-03-27 12:15 Anonymous (not verified) 174.219.134.4 Elijah Willier Proprietorship 805 SE 15th St I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2020-03-27 Elijah Willier e.willier42798@gmail.com Grimes Polk IA Isaac Willier Isaiah Willier Signed (1) The employer does not elect the employers’ liability coverage. Elijah Willier e.willier42798@gmail.com Self/ sole proprietor Grimes Polk IA Isaac Willier Isaiah Willier Signed
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
538 2021-06-08 16:59 Anonymous (not verified) 66.188.136.150 John Sorrentino Proprietorship 808 Dixie Dr. Enterprise, AL 36330 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2021-06-08 John Sorrentino kschumacher@tricorinsurance.com Enterprise Coffee AL Mitch Kemp Shuree Behr Signed (1) The employer does not elect the employers’ liability coverage. John Sorrentino kschumacher@tricorinsurance.com Same Enterprise Coffee AL Mitch Kemp Shuree Behr Signed
853 2022-01-24 08:45 Anonymous (not verified) 173.27.193.218 Matt ruble Limited Liability Company 808 Grandview ave Des Moines Iowa 50316 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-01-23 Matthew ruble gmddetailing2012@gmail.com Des Moines Polk Iowa Matt Ruble Matt Ruble Signed (1) The employer does not elect the employers’ liability coverage. Matt Ruble gmddetailing2012@gmail.com Self Des Moines Polk Iowa Matt Ruble Matt Ruble Signed
1142 2022-06-03 21:35 Anonymous (not verified) 66.43.196.246 Doug ayers Proprietorship 808 Willow st Dumont Iowa 50625 I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. (1) I am not electing the employers’ liability coverage. 2022-06-03 Doug dale ayers dougayers2612@gmail.com Dumont Butler Iowa Amy Pcha David Shear Signed (1) The employer does not elect the employers’ liability coverage. Doug ayers dougayers2612@gmail.com Owner operator Dumont Butler Iowa Amy Picha David Shear Signed