1331 |
2022-10-11 13:17 |
Anonymous (not verified) |
174.216.2.52 |
Parceros Construction LLC |
Limited Liability Company |
2315 Landon Rd. Apt. 206 North Liberty, IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-11 |
Laura Garavito |
ldanielagaravitog@gmail.com |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura Garavito |
ldanielagaravitog@gmail.com |
Owner |
North Liberty |
Johnson |
IA |
Derek Davis |
Cory Beesler |
Signed |
724 |
2021-11-05 14:25 |
Anonymous (not verified) |
209.252.172.87 |
Josh Peterson |
Proprietorship |
121 Karen Drive, Williamsburg, IA 52361 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-15 |
Josh Peterson |
tanyataz@msn.com |
Williamsburg |
Iowa |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Peterson |
tanyataz@msn.com |
Self Employed |
Williamsburg |
Iowa |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
1443 |
2023-02-07 10:05 |
Anonymous (not verified) |
166.181.84.211 |
Leaf home solutions |
Limited Liability Company |
1595 Georgetown rd Hudson Ohio 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-07 |
Dean Martells |
dn.mardesconstruction@gmail.com |
Laporte city |
Benton |
Ia |
Jeromia wilson |
Todd mcknees |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Yurko |
byurko@leacome.com |
Recruiter |
Hudson |
Summit |
Ohio |
Brian mako |
Mat kaulig |
Signed |
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 |
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 |
1667 |
2023-05-29 22:31 |
Anonymous (not verified) |
94.188.207.226 |
All J Acres |
Limited Liability Company |
13522 120th Ave, Ottumwa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-26 |
Jonathan Bunt |
jonbunt@gmail.com |
Ottumwa |
Wapello |
IA |
James Williamson |
James Ash |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathan Bunt |
jonbunt@gmail.com |
Self |
Ottumwa |
Wapello |
IA |
James Williamson |
James Ash |
Signed |
1794 |
2023-08-10 14:56 |
Anonymous (not verified) |
94.188.205.169 |
Alex Kiler |
Proprietorship |
10511 Main Road, La Porte City, IA 50651, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-10 |
Alex Kiler |
alexkiler12622@gmail.com |
La Porte City, IA |
Black Hawk County |
Iowa |
Charles Woods |
Steve Geisler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Charles Wood |
Steven Geisler |
Signed |
1906 |
2023-11-14 13:47 |
Anonymous (not verified) |
94.188.207.223 |
HRBC Plus |
Limited Liability Company |
249 SOLOMIA CT, Peosta, IA 52068 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-11 |
Lori S Stewart |
lori@hrbcplus.com |
PEOSTA |
Dubuque |
United States |
Mark R Stewart |
Danielle M Leibfried |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Stewart |
lori@hrbcplus.com |
Self |
Peosta |
Dubuque |
United States |
Mark R Stewart |
Danielle M Peterson |
Signed |
2018 |
2024-02-01 15:23 |
Anonymous (not verified) |
94.188.205.177 |
SolQ, LLC |
Limited Liability Company |
184 N 100 E STE A Logan, UT 84321 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-01 |
David Bean |
dave@solq.com |
Clarkston |
Cache |
Utah |
Perry M. Koger |
Rebecca Koger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Bean |
dave@solq.com |
Owner |
Logan |
Cache |
Utah |
Perry M. Koger |
Rebecca Koger |
Signed |
2130 |
2024-04-02 09:11 |
Anonymous (not verified) |
94.188.207.229 |
Caliz Stone Services LLC |
Limited Liability Company |
1715 E 21st St, Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-02 |
Marvin Lopez |
marvincaliz843@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Lopez |
marvincaliz843@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
68 |
2020-02-19 12:00 |
Anonymous (not verified) |
198.14.241.59 |
SIERRA ROOFING LLC |
Limited Liability Company |
909 N ELM ST WEST LIBERTY IA 52776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
ABRAHAM GRANJENO |
SIERRA89@GMAIL.COM |
WEST LIBERTY |
MUSCATINE |
IOWA |
JOSE SALGADO |
ALEJANDRIA FRAUSTO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ABRAHAM GANJENO |
SIERRA89@GMAIL.COM |
OWNER |
WEST LIBERTY |
MUSCATINE |
IOWA |
JOSE SALGADO |
ALEJANDRIA FRAUSTO |
Signed |
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 |
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 |
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 |
1011 |
2022-03-28 10:25 |
Anonymous (not verified) |
207.199.231.172 |
Brian Carmer |
Proprietorship |
133 S Iowa Ave, Ottumwa, IA 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-28 |
Brian Carmer |
b_carmer@yahoo.com |
Ottumwa |
Wapello |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Carmer |
B_Carmer@yahoo.com |
Self |
Ottumwa |
Wapello |
Iowa |
James Anderson |
Ashley Bryan |
Signed |
404 |
2021-02-16 13:30 |
Anonymous (not verified) |
174.198.79.179 |
Topline Painting llc |
Limited Liability Company |
1603 e 32nd st Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-16 |
Michael nunez |
toplinepaintingiowa@gmail.com |
Des Moines |
Polk |
Iowa |
Jimmy nunez |
Jose Nunez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael nunez |
toplinepaintingiowa@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Jimmy nunez |
Jose nunez |
Signed |
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 |
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 |
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 |
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 |
1680 |
2023-06-06 12:08 |
Anonymous (not verified) |
94.188.205.168 |
Sipac Drywall |
Proprietorship |
1130 Columbia St, Waterloo, IA 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-06 |
Jennifer Sipac |
jenniferyoung164@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Augie Ferguson |
Wendy Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jennifer Sipac |
jenniferyoung164@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Augie Ferguson |
Wendy Phillips |
Signed |
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 |
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 |
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 |
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 |
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 |
193 |
2020-06-24 11:13 |
Anonymous (not verified) |
173.28.196.82 |
Gray Nation LLC DBA Gray Goat Tattoo |
Limited Liability Company |
116 N 1st Street West Branch, Iowa 52358-9663 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-06-24 |
Elizabeth Gray |
beth.gray516@gmail.com |
West Branch |
Cedar |
Iowa |
Luis Ordenana |
Don Naugthon |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Elizabeth Gray |
beth.gray516@gmail.com |
LLC Member |
West Branch |
Cedar |
Iowa |
Luis Ordenana |
Don Naughton |
Signed |
912 |
2022-02-14 17:51 |
Anonymous (not verified) |
72.168.160.122 |
Mark Weiss |
Proprietorship |
11461 NW Timber Way Granger Iowa 50109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-14 |
Mark Weiss |
kkweiss77@yahoo.com |
Granger |
Polk |
Iowa |
Paul Ness |
Deb Ness |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Casi Sparks |
csparks@destinyhomesusa.com |
Subcontractor |
Waukee |
Dallas |
Iowa |
Paul Ness |
Deb Ness |
Signed |
305 |
2020-11-02 08:40 |
Anonymous (not verified) |
204.124.192.31 |
JPS Framing |
Proprietorship |
102 WALL AVE - DES MOINES IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-02 |
JACKELYN SANCHEZ |
JPSFRAMING629@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
ROGELIO SANCHEZ |
DOMINIQUE SANCHEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUAN SERRANO |
JPSFRAMING629@GMAIL.COM |
EMPLOYER |
DES MOINES |
POLK |
IOWA |
ROGELIO SANCHEZ |
DOMINIQUE SANCHEZ |
Signed |
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 |
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 |
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 |
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 |
1248 |
2022-08-09 11:29 |
Anonymous (not verified) |
166.181.82.131 |
Kelly Kellogg |
Proprietorship |
1305 N 1st st apt 16 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-09 |
Kelly |
Kkell0223@gmail.com |
Indianola |
Warren |
Iowa |
Kelly Kellogg |
Amy Kellogg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Royal flooring |
workorders@shoproyalflooring.com |
Employee |
Urbandale |
Polk |
Iowa |
Amy |
Kelly |
Signed |
641 |
2021-09-17 09:16 |
Anonymous (not verified) |
72.255.121.118 |
Osman Gonzalez-Sarceno |
Proprietorship |
1403 Aspen Dr Adel, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-17 |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Des Moines |
Polk |
IA |
Melissa Bolanos |
Brianna Fuller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Osman Gonzalez-Sarceno |
workorders@shoproyalflooring.com |
Owner |
Des Moines |
Polk |
Iowa |
Melissa Bolanos |
Brianna Fuller |
Signed |
1360 |
2022-11-04 11:13 |
Anonymous (not verified) |
50.81.34.190 |
Rescue 365 Towing & Salvage |
Limited Liability Company |
2569 58th St Vinton, IA 52349 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-04 |
Tyler Schwartz |
rescue365@hotmail.com |
VAN HORNE |
Benton |
IA |
Tony Harmon |
Tracy Beitz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Schwartz |
rescue365@hotmail.com |
Self |
Van Horne |
Benton |
IA |
Tony Harmon |
Tracy Beitz |
Signed |
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 |
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 |
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 |
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 |
1696 |
2023-06-19 09:11 |
Anonymous (not verified) |
94.188.205.174 |
Spruce Cleaning Co |
Proprietorship |
2302 Cedar Street Granger, Iowa 50109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-19 |
Sarah Champion |
Sprucecleaningcodsm@gmail.com |
Granger |
Dallas |
Iowa |
Amy Greek |
Noah Bassett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Champion |
Sprucecleaningcodsm@gmail.com |
Employer |
Granger |
Dallas |
Iowa |
Amy Greek |
Noah Bassett |
Signed |
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 |
1935 |
2023-12-02 18:34 |
Anonymous (not verified) |
94.188.207.229 |
Wasabi Johnston LLC |
Limited Liability Company |
8184 Birchwood Ct, Johnston IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-02 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
Dallas |
IA |
Engjin zheng |
yingna Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
jaywang@wasabidsm.com |
self |
Clive |
Dallas |
IA |
Wenhui Cheng |
Enjing Zheng |
Signed |
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 |
2159 |
2024-04-17 12:28 |
Anonymous (not verified) |
94.188.207.229 |
Mildred Lopez Camacho |
Proprietorship |
214 1st Ave SW Hampton, Iowa 50441 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Jonathan Morales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Jonathan Morales |
Signed |
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 |
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 |
928 |
2022-02-17 19:46 |
Anonymous (not verified) |
208.83.187.211 |
Eric Marsh Trucking LLC |
Limited Liability Company |
1029 Davis Ave Westbrook MN 56183 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Eric Marsh |
emt78@yahoo.com |
Westbrook |
Cottonwood |
MN |
Dustin Krick |
Sam Hansen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Marsh |
emt78@yahoo.com |
Self |
Westbrook |
Cottonwood |
MN |
Dustin Krick |
Sam Hansen |
Signed |
321 |
2020-11-17 10:26 |
Anonymous (not verified) |
173.18.16.129 |
Adam Quimby |
Proprietorship |
2033 10th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-01 |
Adam Quimby |
adam.m.quimby@gmail.com |
Des Moines |
Polk |
Iowa |
Robert Coluzzi |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Quimby |
adam.m.quimby@gmail.com |
Owner |
Des Moines |
Polk |
Iow |
Robert Coluzzi |
Kelly Coluzzi |
Signed |
1040 |
2022-04-12 09:36 |
Anonymous (not verified) |
173.31.148.43 |
PAPA'S SMOKIN MEAT |
Proprietorship |
1940 147TH ST SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-12 |
KEITH MORISTON |
PAPASSMOKINMEAT@GMAIL.COM |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEITH MORISTON |
PAPASSMOKINMEAT@GMAIL.COM |
SELF |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
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 |
1152 |
2022-06-13 13:05 |
Anonymous (not verified) |
70.96.153.153 |
Tyler Ankney |
Proprietorship |
1250 A Ave, Marion, IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-13 |
Tyler Ankney |
tyler.a@optionsexteriors.com |
Marion |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Ankney |
tyler.a@optionsexteriors.com |
Owner |
Marion |
Linn County |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
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 |
1264 |
2022-08-16 21:22 |
Anonymous (not verified) |
50.82.84.19 |
Nogotta Trucking LLC |
Limited Liability Company |
16617 Wilden Dr, Clive IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-16 |
Adam Dickinson |
nogottatruckingllc@gmail.com |
Clive |
IA |
United States |
Gary Dickinson |
Mike Martens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Dickinson |
nogottatruckingllc@gmail.com |
Managing Member |
Clive |
IA |
United States |
Gary Dickinson |
Mike Martens |
Signed |
657 |
2021-09-27 13:55 |
Anonymous (not verified) |
167.142.136.87 |
Crosser Electric,Inc |
Partnership |
PO Box 204 Eldora, Iowa 50627 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-27 |
Marlyn D Crosser |
vhalvorsen@aol.com |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vicki Halvorsen |
vhalvorsen@aol.com |
Partner andf sec/treasurer |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
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 |
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 |
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 |
881 |
2022-02-02 09:39 |
Anonymous (not verified) |
173.215.80.185 |
Tree & Forestry Equipment Inc |
Partnership |
201 Deer Haven St., Polk City, IA 50226 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-02 |
Deborah Frye |
deb@treeandforestry.com |
Polk City |
Polk |
IA |
Joshua Frye |
Phoebe Trent |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Deborah Frye |
deb@treeandforestry.com |
Self |
Polk City |
Polk |
IA |
Joshua Frye |
Phoebe Trent |
Signed |
1600 |
2023-04-25 14:38 |
Anonymous (not verified) |
94.188.207.223 |
martin garcia |
Proprietorship |
219 austin st sw cedar rapids iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-25 |
martin garcia ayala |
martingarcia2100@gmail.com |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
martin garcia ayala |
martingarcia2100@gmail.com |
na |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
1712 |
2023-06-26 20:33 |
Anonymous (not verified) |
94.188.205.167 |
Eastern Iowa Overhead Door |
Proprietorship |
120 N Eliza Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-26 |
Tim Chapin |
easterniadoor@gmail.com |
Maquoketa |
IA |
United States |
Carri Lee Waack |
Wendy Marie Zaruba |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Chapin |
easterniadoor@gmail.com |
Owner |
Maquoketa |
Jackson |
United States |
Carri Lee Waack |
Wendy Marie Zaruba |
Signed |
1839 |
2023-09-12 11:22 |
Anonymous (not verified) |
94.188.205.167 |
J.S. Reeves Consulting LLC |
Limited Liability Company |
1610 1st Ave, Perry, IA 50220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-12 |
joni Sue Reeves |
jonisreeves@att.net |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joni Sue Reeves |
jsreeves67@gmail.com |
Same |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
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 |
2063 |
2024-02-29 10:12 |
Anonymous (not verified) |
94.188.205.177 |
Geral Lee Pattison |
Proprietorship |
22127 Hwy 52 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-29 |
Geral Lee Pattison |
pattisonglee@gmail.com |
GARNAVILLO |
IA |
IA |
Lee Zapf |
Andrew Corllet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Geral Lee Pattison |
pattisonglee@gmail.com |
Self |
GARNAVILLO |
IA |
IA |
Lee Zapf |
Andrew Corllet |
Signed |
2175 |
2024-04-24 09:14 |
Anonymous (not verified) |
94.188.207.229 |
John Sapp |
Proprietorship |
2120 South Main Street Burlington, IA52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-23 |
John Curtis Sapp Jr. |
jbuddysapp@gmail.com |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John C. Sapp Jr. |
jbuddysapp@gmail.com |
owner |
Burlington |
Des Moines |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
113 |
2020-04-07 12:30 |
Anonymous (not verified) |
173.27.33.108 |
Aarron Alley |
Proprietorship |
101 S Teale St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2018-05-15 |
Aarron Alley |
aarronalley10@yahoo.com |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aarron Alley |
aarronalley10@yahoo.com |
Owner |
Davis City |
Decatur |
Iowa |
Joe Fitzgerald |
Steve Young |
Signed |
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 |
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 |
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 |
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 |
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 |
1168 |
2022-06-23 12:57 |
Anonymous (not verified) |
74.84.106.106 |
dora valadez |
Proprietorship |
1244 e 32 nd st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-23 |
dora valadez |
towens@smartind.com |
Des Moines |
Polk |
Iowa |
Tina Owens |
Kim Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
dora valadez |
towens@smartind.com |
self |
Des Moines |
Polk |
Iowa |
Tina Owens |
Kim Owens |
Signed |
561 |
2021-07-08 09:11 |
Anonymous (not verified) |
66.188.136.150 |
Aaron Maldonado dba ATM Trucking |
Proprietorship |
1011 Reynolds Drive, Charleston, IL 61920 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-07 |
Aaron Maldonado dba ATM Trucking |
kschumacher@tricorinsurance.com |
Charleston |
Coles |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Maldonado dba ATM Trucking |
kschumacher@tricorinsurance.com |
Same |
Charleston |
Coles |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
1280 |
2022-08-22 15:48 |
Anonymous (not verified) |
104.222.83.187 |
Cabinet Kulture LLC |
Limited Liability Company |
927 N. West St. Carroll, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-22 |
Jordan Ellis |
cabinetkulture@gmail.com |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cabinet Kulture LLC |
cabinetkulture@gmail.com |
Same person |
Carroll |
IA |
United States |
Morgan Ellis |
Ryan Winkelman |
Signed |
673 |
2021-10-14 07:15 |
Anonymous (not verified) |
97.125.239.203 |
Complete tile llc |
Limited Liability Company |
875 se gateway drive #311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-14 |
Nedzad mustafic |
completetile1@gmail.com |
Grimes |
Usa |
Iowa |
Enesa Mustafic |
Edina avdic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nedzad Mustafic |
completetile1@gmail.com |
Owner |
Grimes |
Usa |
Iowa |
Enesa mustafic |
Edina avdic |
Signed |
1392 |
2022-12-12 11:55 |
Anonymous (not verified) |
173.215.8.119 |
Jones OD PLLC |
Limited Liability Company |
17792 538th St Griswold, IA 51535 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-08 |
Travis Preston Jones |
jonesodpllc@gmail.com |
Griswold |
Pottawattamie |
Iowa |
Kirk Douglas Lantz |
Karla Kay Lantz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Preston Jones |
jonesodpllc@gmail.com |
Officer |
Griswold |
Pottawattamie |
Iowa |
Kirk Douglas Lantz |
Karla Kay Lantz |
Signed |
785 |
2021-12-09 09:15 |
Anonymous (not verified) |
174.198.75.71 |
Daniel Vega camacho |
Proprietorship |
2415 river ,meadows drive Des Moines Iowa 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-09 |
Daniel Vega camacho |
dvega50265@gmail.com |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Vega camacho |
dvega50265@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Chad Smith |
Adam Smith |
Signed |
1504 |
2023-03-07 18:38 |
Anonymous (not verified) |
94.188.207.227 |
Mathias Heating & Cooling |
Limited Liability Company |
1449 19th Pl West Des Moines, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-07 |
Justin Mathias |
emathiasj@gmail.com |
West Des Moines |
Polk |
Iowa |
Jesse Parker |
Jeff Boucher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Mathias |
emathiasj@gmail.com |
Member |
West Des Moines |
Polk |
Iowa |
Jesse Parker |
Jeff Boucher |
Signed |
1616 |
2023-04-27 17:46 |
Anonymous (not verified) |
94.188.207.230 |
Davis AG Service Texas LLC |
Limited Liability Company |
P.O. Box 1475 Fabens, Texas 79838 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-27 |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Anthony Davis |
turbinespacemonkey@yahoo.com |
Owner |
Mountain View |
Stone |
Arkansas |
Vicki Lynne Ivey |
Maggielyn Marie Paul |
Signed |
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 |
1855 |
2023-09-27 12:56 |
Anonymous (not verified) |
94.188.207.224 |
Lincoln Hotel Group |
Limited Liability Company |
9240 Andermatt Drive Suite 1 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-27 |
John Edward Klimpel |
jklimpel@lincolnhotelgroup.com |
Lincoln |
Lancaster |
NE |
Carrie A. Fleck |
Jill N. Korta |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brent Besch |
brent.besch@marshmma.com |
Client |
Lincoln |
Nebraska |
NE |
Carrie A Fleck |
Jill N Korta |
Signed |
1967 |
2023-12-27 13:28 |
Anonymous (not verified) |
94.188.207.225 |
Marvin Gingrich |
Proprietorship |
114641 Chariot Rd Elgin Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-25 |
Marvin Gingerich |
darrele@ciains.biz |
Elgin |
Fayette |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Gingerich |
darrele@ciaisn.biz |
Self |
Elgin |
Fayette |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
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 |
17 |
2019-12-31 09:24 |
Anonymous (not verified) |
72.35.186.80 |
Grgurich Dozing & Tiling, LLC |
Partnership |
PO Box 131, Williamson, IA 50272 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-31 |
Seth Grgurich |
mcbroomt15@gmail.com |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth Grgurich |
mcbroomt15@gmail.com |
Partner |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
2191 |
2024-04-29 10:09 |
Anonymous (not verified) |
94.188.207.225 |
Anthony Rakestraw |
Proprietorship |
1262 S Kellogg St., Galesburg, IL 61401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Anthony Rakestraw |
gazzork2@yahoo.com |
Galesburg |
Know |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Rakestraw |
gazzork2@yahoo.com |
owner |
Galesburg |
Knox |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
129 |
2020-04-24 15:28 |
Anonymous (not verified) |
173.28.28.57 |
Michael Jansen |
Proprietorship |
108 6th Street, Parkersburg, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-10 |
Michael G Jansen |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael G Jansen |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
241 |
2020-08-23 16:10 |
Anonymous (not verified) |
67.45.96.12 |
Wellik & Sons, LLC |
Limited Liability Company |
1770 HWY 18, Garner, IA 50438 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-23 |
Jason Yon Juenger |
j420money@yahoo.com |
Garner |
Hancock |
Iowa |
Joshua P Wellik |
Ashley S Wellik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Paul Wellik |
wellikandsons@gmail.com |
subcontractor |
Garner |
Hancock |
Iowa |
Joshua Paul Wellik |
Ashley S Wellik |
Signed |
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 |
353 |
2021-01-11 14:38 |
Anonymous (not verified) |
66.188.136.150 |
Igor Curguz |
Proprietorship |
927 1/2 W Grand Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-11 |
Igor Curguz |
kschumacher@tricorinsurance.com |
Beloit |
Rock |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Igor Curguz |
kschumacher@tricorinsurance.com |
Same |
Beloit |
Rock |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
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 |
465 |
2021-04-07 22:24 |
Anonymous (not verified) |
173.18.251.105 |
TEMPLEMAN LAWN CARE |
Proprietorship |
1612 Lomas Cr. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-01 |
Tim Lee Templemn |
nancytempleman@gmail.com |
Atlantic |
Iowa |
United States |
Tara Jessen |
Alfred Wede |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Lee Templeman |
nancytempleman@gmail.com |
self |
Atlantic |
Iowa |
Iowa |
Tara Jessen |
Alfred Wede |
Signed |
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 |
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 |
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 |
689 |
2021-10-25 14:38 |
Anonymous (not verified) |
107.197.114.249 |
Brookstin Flooring LLC |
Limited Liability Company |
1702 Brown Deer Rd Coralville IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-10-25 |
Richard T Klemesrud |
rickklemesrud@gmail.com |
CORALVILLE |
IA |
United States |
Brian Woods |
Sherry Woods |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Richard T Klemesrud |
rickklemesrud@gmail.com |
Myself / Owner |
CORALVILLE |
IA |
United States |
Brian Woods |
Sherry Woods |
Signed |
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 |
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 |
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 |
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 |
1744 |
2023-07-13 13:52 |
Anonymous (not verified) |
94.188.205.176 |
T-Rex Construction LLC |
Limited Liability Company |
1203 Bluegrass Circle Unit 4 Cedar Falls Iowa 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-12 |
Claudia Rodriguez De Nunez |
t.rexbigbiz@gmail.com |
CEDAR FALLS |
IA |
United States |
Ana Chavez |
Alicia Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Guillermo Nunez |
claudia.rodriguez.213@gmail.com |
Spouse |
CEDAR FALLS |
IA |
United States |
Alicia Garcia |
Ana Chavez |
Signed |
1871 |
2023-10-18 10:27 |
Anonymous (not verified) |
94.188.205.169 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kylee Lee |
Daryl Eugene Gonyier |
Signed |
1983 |
2024-01-11 13:02 |
Anonymous (not verified) |
94.188.205.168 |
r&k propety solutions |
Proprietorship |
po box 53 cedar rapids iowa 52406 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-11 |
roy rohwedder |
rohwedder.roy@yahoo.com |
Cedar Rapids |
linn |
ia |
Brian Ashlock |
tim vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Center Point |
Benton |
ia |
Tim Vaske |
Roy Rohwedder |
Signed |
2095 |
2024-03-14 11:39 |
Anonymous (not verified) |
205.221.255.62 |
Trimble Lawncare And Landscaping |
Proprietorship |
215 Boundary Ave Middletown IA 52638 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-14 |
Kevin Blake Trimble |
rknhtrimble@yahoo.com |
Middletown |
Des Moines |
Iowa |
Katelyn Orth |
Shayla Taeger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Blake Trimble |
rknhtrimble@yahoo.com |
owner |
Middletown |
Des Moines |
Iowa |
Katelyn Orth |
Shayla Taeger |
Signed |
33 |
2020-01-09 15:57 |
Anonymous (not verified) |
173.28.28.57 |
FALCON PRIDE PROPERTIES LLC |
Limited Liability Company |
1401 HWY 57 PARKERSBURG, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-13 |
TODD THOMAS |
todd@wimcoach.com |
PARKERSBURG |
BUTLER |
IA |
CHAD CAMPBELL |
ROXANNE KOLDER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TODD THOMAS |
todd@wimcoach.com |
SELF |
PARKERSBURG |
BUTLER |
IA |
CHAD CAMPBELL |
ROXANNE KOLDER |
Signed |
2207 |
2024-05-07 09:44 |
Anonymous (not verified) |
94.188.207.226 |
Rodrimart brothers corp |
Limited Liability Company |
958 8th ave nw Altoona 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. |
2024-05-07 |
Enrique Rodriguez |
carluto_1983@hotmail.com |
Altoona |
Polk |
Iowa |
Adan boge |
Lonce wester |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Enrique Rodriguez |
carluto_1983@hotmail.com |
President |
Altoona |
Polk |
Iowa |
Adan boge |
Leans wester |
Signed |
145 |
2020-04-30 16:09 |
Anonymous (not verified) |
173.191.206.253 |
Mark Knapp |
Proprietorship |
11244 Linden Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-30 |
Mark A Knapp |
mlmlknapp@iowatelecom.net |
Linden |
Iowa |
United States |
Phil Hesseltine |
Kathy Hesseltine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Knapp |
mlmlknapp@iowatelecom.net |
self |
Linden |
Iowa |
United States |
Phil Hesseltine |
Kathy Hesseltine |
Signed |
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 |
976 |
2022-03-15 10:44 |
Anonymous (not verified) |
209.152.77.101 |
Bart Fuller & James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln ST., Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-15 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Louise Helmke |
Janice Henningsen |
Signed |
369 |
2021-01-22 10:02 |
Anonymous (not verified) |
66.188.136.150 |
Rick Swaney |
Proprietorship |
1551 Persimmon, Stilwell, OK 74960 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-22 |
Rick Swaney |
kschumacher@tricorinsurance.com |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Swaney |
kschumacher@tricorinsurance.com |
Same |
Stilwell |
Adair |
OK |
Russell Masartis |
Shuree Behr |
Signed |
1088 |
2022-05-04 16:00 |
Anonymous (not verified) |
50.80.16.238 |
American Gutter Company LLC |
Proprietorship |
2015 Andrew Charles Dr NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-04 |
John Kuper |
american.guttercompanyllc@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Kirstin Hagerty |
Vic Kuper |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Kuper |
american.guttercompanyllc@gmail.com |
Owner |
CEDAR RAPIDS |
Linn |
IA |
Kirstin Hagerty |
Vic Kuper |
Signed |
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 |
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 |
593 |
2021-08-03 12:29 |
Anonymous (not verified) |
184.12.14.229 |
SS Docks LLC |
Limited Liability Company |
PO Box 561, Okoboji, IA 51355-0561 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-05-21 |
Jason Snow |
k.kooima@q.com |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jason Snow - SS Docks LLC |
k.kooima@q.com |
Owner |
Okoboji |
Dickinson |
Iowa |
Mabel Behnke |
Brandi Parks |
Signed |
1312 |
2022-09-17 15:29 |
Anonymous (not verified) |
97.125.242.121 |
Heartland Blinds |
Limited Liability Company |
1255 Emmons St, Hiawatha, IA 52233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-17 |
Phil Murray |
proinstallia@yahoo.com |
Hiawatha |
Linn |
IA |
Jared Metcalf-Murray |
Jeremy Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christene Murray |
chrissymurray57@yahoo.com |
Self |
Hiawatha |
Linn |
IA |
Jared Metcalf-Murray |
Jeremy Murray |
Signed |
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 |
1424 |
2023-01-17 17:34 |
Anonymous (not verified) |
173.191.246.189 |
Jabe Ramsey |
Proprietorship |
216 South Park Street Osceola, IA 50213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-17 |
Jabe Hatfield Ramsey |
jaberamsey@icloud.com |
Osceola |
IA |
United States |
Sofia Contreras |
Katie Anne Carson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jabe Ramsey |
jaberamsey@icloud.com |
ME |
Osceola |
Clarke |
IOWA |
Sofia Contreras |
Katie Anne Carson |
Signed |
817 |
2021-12-30 12:58 |
Anonymous (not verified) |
50.80.80.37 |
Leaf Filter |
Limited Liability Company |
1595 Georgetown Road Hudson, OH 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-30 |
Kenneth Van Hook |
kennyvanhook1976@gmail.com |
Port Byron |
Rock Island |
IL |
Sharon Van Hook |
Judy Hoffman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Dunbar |
cdunbar@leaffilter.com |
Manager |
Bettendorf |
Scott County |
IA |
Cody Dunbar |
Jordan Nisiewicz |
Signed |
1536 |
2023-03-27 10:47 |
Anonymous (not verified) |
94.188.205.174 |
Cecile C Knipp |
Limited Liability Company |
1418 Oakcrest Dr., Waterloo, IA 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-27 |
Cecile C Knipp |
ceilknipp@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Monica Robbins |
Anne Betts |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cecile C Knipp |
christinaknipp@aol.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Monica Robbins |
Anne Betts |
Signed |
1648 |
2023-05-16 08:16 |
Anonymous (not verified) |
94.188.205.169 |
Hernandez Drywall |
Proprietorship |
2001 8th St Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-16 |
Gerardo Hernandez |
gerardohernandez56u@gmail.com |
Coralville |
Johnson |
Iowa |
Brad Bower |
Kirk Strucnk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerardo Hernandez |
gerardohernandez56u@gmail.com |
Self |
Coralville |
Johnson |
iowa |
Brad Bower |
Kirk Strunk |
Signed |
1775 |
2023-08-03 09:37 |
Anonymous (not verified) |
94.188.207.227 |
J j builder llc |
Limited Liability Company |
2307 richland dr des moines ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-28 |
José Cruz Jasso balleza |
jassoprimo03@icloud.com |
Des moines |
Polk |
Iowa |
Jaime Rodrigues |
Mario ramos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Irving |
iibarra@centroinsurance.com |
Agent |
Des moines |
Polk |
Iowa |
Irving Ibarra |
Jaime Rodrigues |
Signed |
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 |
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 |
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 |
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 |
49 |
2020-01-31 12:53 |
Anonymous (not verified) |
74.84.121.206 |
Cody Kleppe |
Proprietorship |
1891 337th St Decorah IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-31 |
Cody Kleppe |
darrele@ciains.biz |
Decorah |
Winneshiek |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Decorah |
Winneshiek |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
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 |
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 |
992 |
2022-03-21 19:42 |
Anonymous (not verified) |
174.192.66.11 |
Christopher Binns |
Proprietorship |
1324 Grand Ave, Davenport, IA 52803 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-21 |
Christopher Binns |
christophersbinns@gmail.com |
Davenport |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Binns |
christophersbinns@gmail.com |
same |
Davenport |
Scott |
IA |
Adam Coleman |
Rose Snyder |
Signed |
385 |
2021-02-07 12:43 |
Anonymous (not verified) |
173.17.12.148 |
H@E roofing LLC |
Limited Liability Company |
1912 Burson street Des Moines is 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-04 |
Heather Hickman |
hratherhickman@gmail.com |
Des moines |
Polk |
Iowa |
Jerry freeborn |
Ivan torres |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heather Hickman |
hratherhickman@gmail.com |
Self |
Des moines |
Polk |
Iowa |
Jerry freeborn |
Ivan torres |
Signed |
1104 |
2022-05-16 13:00 |
Anonymous (not verified) |
65.144.174.26 |
Medrano Flooring LLC |
Limited Liability Company |
8186 Harbach Blvd Apt 1, Clive, IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
Joel Medrano |
medranojoel397@gmail.com |
Clive |
Polk |
Iowa |
Ana Leon |
Jesus Maldonado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Medrano |
medranojoel397@gmail.com |
Self |
Clive |
Polk |
Iowa |
Ana Leon |
Jesus Maldonado |
Signed |
497 |
2021-04-27 09:25 |
Anonymous (not verified) |
204.153.176.147 |
SHANE HUCK |
Proprietorship |
1070 305TH STREET, NASHUA, IOWA 50658 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-27 |
SHANE HUCK |
WOODHUCK@GMAIL.COM |
NASHUA |
CHICKASAW |
IOWA |
KIM LOECKLE |
RACHEL SCHNEIDER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHANE HUCK |
WOODHUCK@GMAIL.COM |
OWNER |
NASHUA |
CHICKASAW |
IOWA |
KIM LOECKLE |
RACHEL SCHNEIDER |
Signed |
1216 |
2022-07-20 16:24 |
Anonymous (not verified) |
208.38.231.24 |
Leaf Filter |
Limited Liability Partnership |
866 40th ave Bettendorf IA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-19 |
Savannah Taets |
savannahtaets@gmail.com |
Davenport |
Scott |
Iowa |
Savannah Taets |
Layman Miller |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jennifer Stricklett |
jennifer.stricklett@suracy.com |
Insurance agent |
Davenport |
Scott |
Iowa |
Savannah Taets |
Layman Miller |
Signed |
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 |
1328 |
2022-10-07 22:45 |
Anonymous (not verified) |
50.82.178.112 |
Compass Commercial Services LLC |
Limited Liability Company |
1950 Boyson road, Hiawatha, Ia 52233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-07 |
Patrick Roland |
mastershineservices@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Aubrey Hantz |
Brenna Trinkle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Fortanini |
bfontanini@compassbuilt.com |
Project Manager |
Hiawatha |
Linn |
Iowa |
Aubrey Hantz |
Brenna Trinkle |
Signed |
721 |
2021-11-05 14:04 |
Anonymous (not verified) |
209.252.172.87 |
Mike Kraus |
Proprietorship |
212 2nd St Buffalo, Ia 52728 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-17 |
Mike Kraus |
mjkraus4356@gmail.com |
Buffalo |
Scott |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Kraus |
mjkraus4356@gmail.com |
Self Employed |
Buffalo |
Scott |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
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 |
833 |
2022-01-12 17:30 |
Anonymous (not verified) |
67.212.111.166 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161 Cedar Falls, Iowa 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-13 |
Steven John Swanson |
studio7sjs@gmail.com |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Braden L Gray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
Cedar Falls |
Black Hawk County |
Iowa |
Kari Houle |
Braden L Gray |
Signed |
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 |
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 |
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 |
1903 |
2023-11-13 09:08 |
Anonymous (not verified) |
94.188.207.228 |
Christopher Stone |
Proprietorship |
2427 S Taft Ave Apt #8 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-10 |
Christopher Stone |
darrele@ciains.biz |
Iowa |
Cerro Gordo |
IA |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Stone |
darrele@ciains.biz |
self |
Mason City |
Cerro Gordo |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
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 |
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 |
65 |
2020-02-18 15:44 |
Anonymous (not verified) |
70.58.180.91 |
TD & I CABLE MAINTENANCE INC. |
Proprietorship |
P.O. BOX 266 LAKELAND MN. 55043 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-18 |
FREDERICK W GREEN |
FREDGREENCONSTRUCTION@YAHOO.COM |
DES MOINES |
POLK |
IOWA |
KATHYRN EILEEN WILLIAMSON |
MICHAEL BOYD WILLIAMS |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LIZZY SHEPARD |
LIZZYSHEPARD@TDICABLE.COM |
SUBCONTRACTOR |
LAKELAND |
WASHINGTON |
MINNESOTA |
KATHRYN EILEEN WILLIAMSON |
MICHAEL BOYD WILLIAMS |
Signed |
177 |
2020-06-08 11:00 |
Anonymous (not verified) |
173.28.28.57 |
Lakeview Retreat Center, LLC |
Limited Liability Company |
17726 260th Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-23 |
Kendale Winkowitsch |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kendale Winkowitsch |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
896 |
2022-02-04 11:58 |
Anonymous (not verified) |
198.167.180.146 |
Northtowne Market Lot 7, LLC |
Limited Liability Company |
1005 Blairs Ferry Road NE, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-04 |
Benjamin Wickum |
bwickum@collinscu.org |
CEDAR RAPIDS |
Linn |
Iowa |
Jody Comried |
Pat Milke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Benjamin Wickum |
bwickum@collinscu.org |
Manager |
Cedar Rapids |
Linn |
Iowa |
Jody Comried |
Pat Milke |
Signed |
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 |
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 |
401 |
2021-02-15 14:50 |
Anonymous (not verified) |
66.188.136.150 |
Jarrod Wernimont |
Proprietorship |
24 Blackhawk Rd. Hanover, IL 61041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-12 |
Jarrod Wernimont |
kschumacher@tricorinsurance.com |
Hanover |
Jo Daviess |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jarrod Wernimont |
kschumacher@tricorinsurance.com |
Same |
Hanover |
Jo Daviess |
IL |
Russell Masartis |
Shuree Behr |
Signed |
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 |
513 |
2021-05-11 13:14 |
Anonymous (not verified) |
173.31.147.225 |
RUTHVEN ROCKS LLC |
Limited Liability Company |
1205 ROLLING ST RUTHVEN IOWA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-11 |
KEITH CACEK |
KEITH@RUTHVENROCKS.COM |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KEITH CACEK |
joel@walkerinsuranceia.com |
MEMBER |
RUTHVEN |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1232 |
2022-07-28 18:27 |
Anonymous (not verified) |
50.83.189.149 |
Eagle Construction Co LLC |
Limited Liability Company |
1150 county line rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-28 |
Carlos Flores |
eagleconstruciontco.865@gmail.com |
Des Moines |
Warren |
Iowa |
Morgan Conrard |
Ronika Htu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carlos Flores |
eagleconstruciontco.865@gmail.com |
Owner |
Des Moines |
Warren |
IA |
Morgan Conrard |
Ronika Htu |
Signed |
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 |
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 |
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 |
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 |
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 |
1916 |
2023-11-21 12:31 |
Anonymous (not verified) |
94.188.205.174 |
DC Painting |
Proprietorship |
205 Astor St, Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-03 |
Damion Clement |
gcort06@gmail.com |
Des Moines |
Polk |
IA |
Brandi Haight |
Dennis Clement |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Damion Clement |
gcort06@gmail.com |
Owner |
205 Astor Street |
Polk |
IA |
Brandi Haight |
Dennis Clement |
Signed |
2028 |
2024-02-07 09:41 |
Anonymous (not verified) |
94.188.207.228 |
J & J SIDING |
Proprietorship |
214 6TH STREET, P.O. BOX 482, LAKE VIEW, IOWA 51450 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-07 |
JOHN CLARENCE OLERICH |
bigo@netins.net |
LAKE VIEW |
SAC |
IOWA |
ROBERT EUGENE BELT |
NEIL THIESSEN MARTENS |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOHN CLARENCE OLERICH |
bigo@netins.net |
SELF |
LAKE VIEW |
SAC |
IOWA |
ROBERT EUGENE BELT |
NEIL THIESSEN MARTENS |
Signed |
2140 |
2024-04-09 09:28 |
Anonymous (not verified) |
94.188.205.175 |
Bart Fuller& James Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln Street Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-09 |
Bart Fuller |
goffins@ruthventel.com |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bart Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
PAlo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
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 |
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 |
909 |
2022-02-10 08:03 |
Anonymous (not verified) |
166.181.83.242 |
Kim Hildebrand |
Proprietorship |
130 Sabrina cir Waterloo, IA 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-07 |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kimberly Kay Hildebrand |
kimregenold@yahoo.com |
Self |
Waterloo |
Blackhawk |
Iowa |
Darrin Hildebrand |
Stephanie Nerison |
Signed |
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 |
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 |
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 |
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 |
526 |
2021-05-19 09:36 |
Anonymous (not verified) |
66.188.136.150 |
John Robinson |
Proprietorship |
12990 E 48th Ave. Denver, CO 80239 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-18 |
John Robinson |
kschumacher@tricorinsurance.com |
Denver |
Denver |
CO |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Robinson |
kschumacher@tricorinsurance.com |
Same |
Denver |
Denver |
CO |
Mitch Kemp |
Shuree Behr |
Signed |
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 |
638 |
2021-09-13 09:18 |
Anonymous (not verified) |
74.84.91.178 |
Thomas Tremble |
Proprietorship |
1209 University Avenue, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-09 |
Thomas Tremble |
TJTremble21@gmail.com |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Derrick Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Tremble |
TJTremble21@gmail.com |
self |
Dubuque |
Dubuque |
Iowa |
Gabe Drewelow |
Derrick Parsons |
Signed |
1357 |
2022-11-03 15:06 |
Anonymous (not verified) |
66.129.196.99 |
Blake Carson |
Limited Liability Company |
1550 plainview rd ely, IA 52227 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-21 |
Blake Dennis Carson |
Blake@carsondesignsco.com |
Ely |
Linn |
iowa |
Dennis Carson |
Jordan Mellinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Carson |
Blake@carsondesignsco.com |
member/Owner |
Ely |
linn |
iowa |
Dennis Carson |
Jordan Mellinger |
Signed |
750 |
2021-11-16 12:34 |
Anonymous (not verified) |
172.58.83.130 |
Austin Carlson |
Proprietorship |
1341 iron city avenue atalissa Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-16 |
Austin Carlson |
toppeakconstruction@gmail.com |
Atalissa |
Muscating |
Iowa |
Jordan Nisiewicz |
Sam Apponey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jorden Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Jackson |
Missouri |
Jordan Nisiewicz |
Sam Apponey |
Signed |
1469 |
2023-02-19 18:23 |
Anonymous (not verified) |
94.188.205.169 |
Superior Sheet Metal LLC |
Limited Liability Company |
1819 MM Ave Marengo, IA 52301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-19 |
Adam Lynn Nielsen |
adamnielsen4@yahoo.com |
Marengo |
Iowa |
United States |
Emily Jean Nielsen |
Joseph Daryl Kriegel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Lynn Nielsen |
adamnielsen4@yahoo.com |
Self |
Marengo |
Iowa |
Iowa |
Emily Jean Nielsen |
Joseph Daryl Kriegel |
Signed |
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 |
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 |
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 |
1820 |
2023-08-28 08:12 |
Anonymous (not verified) |
94.188.205.177 |
LLAD Services LLC |
Limited Liability Company |
1611 Esplanade Avenue Davenport IA 52803 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-28 |
Austin Lee Terry |
austinfarrell92@gmail.com |
Davenport |
Scott |
Iowa |
Cody Dunbar |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
JNisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Cody Dunbar |
Jordan Loyd |
Signed |
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 |
2044 |
2024-02-15 09:52 |
Anonymous (not verified) |
94.188.205.168 |
Messenger Trucking LLC |
Limited Liability Company |
1869 255th St., Fairfield, IA 52556 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Timothy Duncan Messenger |
tmessengertrucking@gmail.com |
Fairfield |
Jefferson |
Iowa |
Casey Messenger |
Bud Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Duncan Messenger |
tmessengertrucking@gmail.com |
Self |
Fairfield |
Jefferson |
Iowa |
Casey Messenger |
Bud Smith |
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 |
94 |
2020-03-18 13:18 |
Anonymous (not verified) |
174.243.114.80 |
Sogard Excavating |
Limited Liability Company |
2374 380th St, Jewell, IA 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-18 |
Jon A Sogard |
jsogard22@gmail.com |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sogard Excavating LLC |
jsogard22@gmail.com |
owner |
Jewell |
Hamilton |
IA |
Fallon Sogard |
Julee Lund |
Signed |
206 |
2020-07-16 08:18 |
Anonymous (not verified) |
97.64.194.122 |
Tommy Messino |
Proprietorship |
205 S Taylor St., Cherry, IL 61317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-10 |
Tommy Messino |
kschumacher@tricorinsurance.com |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tommy Messino |
kschumacher@tricorinsurance.com |
Same |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
925 |
2022-02-17 13:07 |
Anonymous (not verified) |
208.81.192.69 |
Wapsie Valley Construction, LLC |
Limited Liability Company |
1154 Dennison Ave., Fairbank, IA 50629 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Chester H. Borntrager |
accounting@robertseddy.com |
Hazleton |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Merle Miller |
accounting@robertseddy.com |
Same person |
Fairbank |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
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 |
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 |
430 |
2021-03-10 13:01 |
Anonymous (not verified) |
192.30.185.142 |
Trey LaGois Construction |
Proprietorship |
132 W Cedar St, Hinton, IA 51024 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
Trey LaGois |
treylagois2015@gmail.com |
Hinton |
Plymouth |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trey LaGois |
treylagois2015@gmail.com |
Owner |
Hinton |
Plymouth |
IA |
Katie Jenks |
Nate Blaeser |
Signed |
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 |
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 |
1261 |
2022-08-16 11:30 |
Anonymous (not verified) |
173.29.47.222 |
Premiere Plastering & Drywall, Inc. |
Proprietorship |
2331 W. 63rd St., Davenport, IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-16 |
Jacob Dreifurst |
j_dreifurst@yahoo.com |
Colona |
Henry |
Illinois |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
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 |
1373 |
2022-11-16 12:28 |
Anonymous (not verified) |
173.22.187.22 |
MCDONALD'S LAWN & TREE SERVICES |
Proprietorship |
1130 N. 4 AVE. W. NEWTON IA 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-16 |
Roger McDonald |
RABBITMCDONALD@HOTMAIL.COM |
Newton |
IA |
United States |
Patricia McMahon |
Bryan McMahon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger McDonald |
RABBITMCDONALD@HOTMAIL.COM |
Self |
Newton |
IA |
United States |
Patricia McMahon |
Bryan McMahon |
Signed |
766 |
2021-11-22 16:19 |
Anonymous (not verified) |
63.229.189.35 |
Tribal Tile, LLC |
Limited Liability Company |
1402 Ithaca Ave, Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Josh Loerzel |
joshloerzel@gmail.com |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Loerzel |
joshloerzel@gmail.com |
Self |
SPIRIT LAKE |
Dickinson |
IA |
Abigail Miles |
Alex Miles |
Signed |
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 |
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 |
1597 |
2023-04-24 16:03 |
Anonymous (not verified) |
94.188.207.224 |
4 Iowa Construction LLC |
Limited Liability Company |
1750 Lyon St Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-24 |
Luis E Cancino Mireles |
luiscancino55@gmail.com |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis E Cancino Mireles |
luiscancino55@gmail.com |
self / 100% owner / manager of the LLC |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
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 |
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 |
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 |
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 |
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 |