2131 |
2024-04-02 10:28 |
Anonymous (not verified) |
94.188.205.168 |
Driskell Spray, LLC |
Limited Liability Company |
1279 300th Ave Sidney, IA 51652 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-22 |
Jamie Driskell |
driskell216@gmail.com |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jamie Driskell |
driskell216@gmail.com |
owner |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
2001 |
2024-01-26 10:41 |
Anonymous (not verified) |
94.188.207.225 |
4 Sons Splicing & Activation |
Proprietorship |
13510 W Brazos Bend Dr, Needville, TX 77461-9525 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-26 |
John Kevin Steil |
foursons1990@steil.org |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Helen Frances Steil |
foursons1990@steil.org |
Spouse |
Needville |
Ft. Bend |
Texas |
Dennis Reeves Oliver |
Stephanie Ranae Oliver |
Signed |
1090 |
2022-05-06 08:08 |
Anonymous (not verified) |
65.111.39.23 |
Farr TRucking Inc |
Proprietorship |
2206 E Locust Ln, Table Grove, IL 61482 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-06 |
Donald Paul Farr |
howthewestisdone@gmail.com |
Table Grove |
Fulton |
Illinois |
Tamra Stambaugh |
Keith Allard |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DeYonne L Farr |
howthewestisdone@gmail.com |
Secretary |
Table Grove |
Fulton |
Illinois |
Tamra Stambaugh |
Keith Allard |
Signed |
172 |
2020-06-02 15:56 |
Anonymous (not verified) |
66.188.136.150 |
David Bull |
Proprietorship |
221 N Aarlocker St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-02 |
David Bull |
kschumacher@tricorinsurance.com |
Mount Hope |
Grant |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Bull |
kschumacher@tricorinsurance.com |
Same |
Mount Hope |
Grant |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
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 |
910 |
2022-02-10 15:46 |
Anonymous (not verified) |
184.100.98.101 |
Carich properties |
Proprietorship |
6842 Fawn Rd. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-10 |
Chris Richard |
ticketbarandgrill@gmail.com |
Platteville |
Grant |
Wisconsin |
Allison Richard |
Melodee Richard |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Richard |
ticketbarandgrill@gmail.com |
Owner |
Platteville |
Grant |
Wisconsin |
Allison Richard |
Melodee Richard |
Signed |
1904 |
2023-11-13 09:27 |
Anonymous (not verified) |
94.188.207.224 |
Paul White |
Proprietorship |
4991 Old C Boscobel, WI 53805 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-10 |
Paul White |
darrele@ciains.biz |
Boscobel |
Grant |
Wisconsin |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul White |
darrele@ciains.biz |
self |
Boscobel |
Grant |
Wisconsin |
Chris Fye |
Darrel Elsbernd |
Signed |
427 |
2021-03-10 11:52 |
Anonymous (not verified) |
66.188.136.150 |
Ronald Tessen |
Proprietorship |
493 Hill St. Green Lake, WI 54941 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
Ronald Tessen |
kschumacher@tricorinsurance.com |
Green Lake |
Green Lake |
WI |
Russell Masartis |
Amanda Seeberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald Tessen |
kschumacher@tricorinsurance.com |
Same |
Green Lake |
Green Lake |
WI |
Russell Masartis |
Amanda Seeberger |
Signed |
81 |
2020-02-25 17:31 |
Anonymous (not verified) |
66.43.239.175 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-25 |
Abby Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Dena M. Anderson |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Glendenning |
lanceandabby@wccta.net |
President |
Churdan |
Greene |
IA |
Dena M Anderson |
Shelly Brus |
Signed |
82 |
2020-02-25 17:32 |
Anonymous (not verified) |
66.43.239.175 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-25 |
Lance Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Dena M. Anderson |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
lanceandabby@wccta.net |
Officer |
Churdan |
Greene |
IA |
Dena M Anderson |
Shelly Brus |
Signed |
199 |
2020-07-09 10:49 |
Anonymous (not verified) |
167.142.98.40 |
Ryan Stott |
Proprietorship |
1513 Hawthorne Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-09 |
Ryan Lynn Stott |
rlstott@hotmail.com |
Jefferson |
Greene |
Iowa |
Brock Chisum |
Brian Chisum |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Stott |
rlstott@hotmail.com |
self |
Jefferson |
Greene |
Iowa |
Brock Chisum |
Brian Chisum |
Signed |
417 |
2021-03-03 13:49 |
Anonymous (not verified) |
173.215.42.12 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-03 |
Lance Jeffrey Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Shelly L. Brus |
Dena M. Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
accounting@lynxag.com |
Officer |
Churdan |
Greene |
Iowa |
Shelly L. Brus |
Dena M. Anderson |
Signed |
418 |
2021-03-03 13:50 |
Anonymous (not verified) |
173.215.42.12 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-03 |
Abigail Jayne Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Shelly L. Brus |
Dena M. Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Jeffrey Glendenning |
lanceandabby@wccta.net |
President |
Churdan |
Greene |
Iowa |
Shelly L. Brus |
Dena M. Anderson |
Signed |
527 |
2021-05-20 07:54 |
Anonymous (not verified) |
66.43.242.142 |
mcconnells custom construction |
Proprietorship |
1074 240th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
John McConnell |
jnkatmcc@netins.net |
jefferson |
greene |
ia |
Jordan Hostetler |
Mark Aspengren |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
McConnell's Custom Construction |
jnkatmcc@netins.net |
owner |
jefferson |
greene |
ia |
Jordan Hostetler |
Mark Aspengren |
Signed |
971 |
2022-03-14 17:59 |
Anonymous (not verified) |
207.32.37.48 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan, IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Lance Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
accounting@lynxag.com |
Officer |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
972 |
2022-03-14 18:01 |
Anonymous (not verified) |
207.32.37.48 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan, IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Abby Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Glendenning |
lanceandabby@wccta.net |
President |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
148 |
2020-05-04 15:49 |
Anonymous (not verified) |
173.28.28.57 |
LaRae Randall dba Wild Soul Photo |
Proprietorship |
19019 O Avenue, Grundy Center, IA 50638 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
LaRae Randall |
cmins_re@mchsi.com |
Grundy Center |
Grundy |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LaRae Randall |
cmins_re@mchsi.com |
Self |
Grundy Center |
Grundy |
IA |
Chad Campbell |
Roxanne Kolder |
Signed |
606 |
2021-08-17 12:25 |
Anonymous (not verified) |
69.57.199.231 |
Precision Painting |
Proprietorship |
507 Broad St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-08-17 |
Daniel Paul Bowser |
danshonda12@gmail.com |
Reinbeck |
Grundy |
Iowa |
David Paul Bowser |
Mary Ellen Sue Bowser |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Sinnott Agency |
toms@sinnottagency.com |
Insurance provider |
Waterloo |
Blackhawk |
Iowa |
David Paul Bowser |
Mary Ellen Sue Bowser |
Signed |
607 |
2021-08-17 12:31 |
Anonymous (not verified) |
69.57.199.231 |
Precsion Painting |
Proprietorship |
507 Broad St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-17 |
Daniel Paul Bowser |
danshonda12@gmail.com |
Reinbeck |
Grundy |
Iowa |
David Paul Bowser |
Mary Ellen Sue Bowser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sinnott Agency |
toms@sinnottagency.com |
Insurance provider |
Waterloo |
Blackhawk |
Iowa |
David Paul Bowser |
Mary Ellen Sue Bowser |
Signed |
40 |
2020-01-19 13:20 |
Anonymous (not verified) |
167.142.82.171 |
Arganbright Land Improvement LLC |
Limited Liability Company |
2440 Redwood Ave. Guthrie Center, IA 50115 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-19 |
Josh Arganbright |
josh@arganbrightlandimp.com |
Guthrie Center |
Guthrie |
IA |
Kim Bauer |
Tom Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Arganbright |
josh@arganbrightlandimp.com |
self |
Guthrie Center |
Guthrie |
IA |
Kim Bauer |
Tom Smith |
Signed |
324 |
2020-11-20 09:08 |
Anonymous (not verified) |
71.39.227.238 |
County-Line Construction, LLC |
Limited Liability Company |
314 NE 2nd St, Panora, IA 50216 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-20 |
John Steve Vogel |
thevogels@netins.net |
Panora |
Guthrie |
Iowa |
Steve Phillips |
Abbey Luellen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Steve Vogel |
thevogels@netins.net |
Owner |
Panora |
Guthrie |
Iowa |
Steve Phillips |
Abbey Luellen |
Signed |
422 |
2021-03-05 13:53 |
Anonymous (not verified) |
71.39.227.238 |
Steven Phillips |
Proprietorship |
1107 Walnut St, Dallas Center, IA 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-06 |
Steven Phillips |
stevep@phillipsassociatesins.net |
Linden |
Guthrie |
Iowa |
Abbey Luellen |
RoseMary Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Phillips |
stevep@phillipsassociatesins.net |
Self |
Linden |
Guthrie |
Iowa |
RoseMary Phillips |
Abbey Luellen |
Signed |
423 |
2021-03-05 13:55 |
Anonymous (not verified) |
71.39.227.238 |
RoseMary Phillips |
Proprietorship |
1107 Walnut St, Dallas Center, IA 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-05 |
RoseMary Phillips |
stevep@phillipsassociatesins.net |
Linden |
Guthrie |
Iowa |
Steven Phillips |
Abbey Luellen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RoseMary Phillips |
stevep@phillipsassociatesins.net |
Self |
Linden |
Guthrie |
Iowa |
Steve Phillips |
Abbey Luellen |
Signed |
571 |
2021-07-12 09:51 |
Anonymous (not verified) |
67.55.237.31 |
Steve Vogel |
Proprietorship |
314 NE 2ND ST. Panora, Iowa 50216-2020 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-12 |
Steve Vogel |
thevogels@netins.net |
PANORA |
Guthrie |
United States |
Diana Vogel |
Adam Vogel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Vogel |
thevogels@netins.net |
Self |
PANORA |
Guthrie |
Iowa |
Diana Vogel |
Adam Vogel |
Signed |
936 |
2022-02-25 10:47 |
Anonymous (not verified) |
173.215.112.17 |
Arganbright Home Construction LLC |
Limited Liability Company |
2251 Soldier Trail, Panora, IA 50216 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-25 |
David E Arganbright |
davearganbright@netins.net |
Panora |
Guthrie |
IA |
Cindy J Carstens |
Andrew Randol |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christine M Arganbright |
chrisbia@netins.net |
Member |
Panora |
Guthrie |
IA |
Cindy J Carstens |
Andrew Randol |
Signed |
1253 |
2022-08-12 14:43 |
Anonymous (not verified) |
173.23.251.188 |
GLBH, LLC |
Proprietorship |
3396 268th St Linden, IA 50146 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-12 |
Gavin Lamb |
gavinglbh@outlook.com |
Linden |
Guthrie |
IA |
Tara Murphy |
Nick Stevens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gavin Lamb |
gavinglbh@outlook.com |
self |
Linden |
Guthrie |
IA |
Tara Murphy |
Nick Stevens |
Signed |
1554 |
2023-04-04 16:30 |
Anonymous (not verified) |
94.188.205.176 |
House of Bean Studios |
Limited Liability Company |
2066 170th Street, Guthrie Center, IA 50115 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-04 |
Nicole Jazzmin Bean |
nicolebean.studios@gmail.com |
Guthrie Center |
Guthrie |
Iowa |
Daniel Bean |
Anthony Durst |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Jazzmin Bean |
houseofbeanstudios@gmail.com |
Self (Sole-proprietor LLC) |
Guthrie Center |
Guthrie |
Iowa |
Daniel Bean |
Anthony Durst |
Signed |
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 |
221 |
2020-08-03 12:03 |
Anonymous (not verified) |
167.142.196.238 |
Israel Moreno |
Proprietorship |
Po Box 186 Williams, IA 50271 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Israel Moreno |
mikjuniormoreno@hotmail.com |
Williams |
Hamilton |
Iowa |
Justin J Malloy |
Myndi Grimsley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Israel Moreno |
mikjuniormoreno@hotmail.com |
owner |
Williams |
Hamilton |
Iowa |
Justin J Malloy |
Myndi Grimsley |
Signed |
270 |
2020-09-25 10:14 |
Anonymous (not verified) |
174.243.97.206 |
J Watts Electric |
Limited Liability Company |
615 E 2nd St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-25 |
Jason Watts |
jason.watts@jwattselectric.com |
Webster City |
Hamilton |
Iowa |
Eli Ochoa |
Cody Ewing |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Watts |
jason.watts@jwattselectric.com |
Self |
Webster City |
Hamilton |
Iowa |
Eli Ochoa |
Cody Ewing |
Signed |
341 |
2020-12-23 08:52 |
Anonymous (not verified) |
174.243.82.219 |
Jason D Struchen |
Proprietorship |
1778 210th St Webster City, IA 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-23 |
Jason David Struchen |
steruchen75@gmail.com |
Webster City |
Hamilton |
Iowa |
NA |
NA |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason D Struchen |
struchen75@gmail.com |
Same |
Webster City |
Hamilton |
Iowa |
NA |
NA |
Signed |
415 |
2021-03-01 17:06 |
Anonymous (not verified) |
208.126.61.78 |
Fryes Tree Service |
Proprietorship |
P.O. Box 244 Webster City, IA 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-01 |
Don Johnson |
fts.don@gmail.com |
Webster City |
Hamilton |
IA |
Jenna Shaw |
Tim Turner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Don Johnson |
fts.don@gmail.com |
Owner |
Webster City |
Hamilton |
IA |
Jenna shaw |
Tim Turner |
Signed |
614 |
2021-08-20 12:20 |
Anonymous (not verified) |
172.58.235.242 |
Darren Qualls |
Proprietorship |
1515 Dewitt St. Ellsworth. IA 50075 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-20 |
Darren Wade Qualls |
d.qualls@outlook.com |
Ellsworth |
Hamilton |
IA |
Jeannie Kathleen Qualls |
Andrea Littleton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darren Wade Qualls |
d.qualls@outlook.com |
Self/Proprietor |
Ellsworth |
IA |
IA |
Jeannie Kathleen Qualls |
Andrea Littleton |
Signed |
828 |
2022-01-11 10:34 |
Anonymous (not verified) |
74.215.151.63 |
Marr Arnold Planning |
Limited Liability Company |
1328 California Ave. Ames Iowa 50014 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-11 |
Sarah Arnold |
sarahkarnold@gmail.com |
Cincinnati |
Hamilton |
Ohio |
April Humphreys |
Amy Burns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Arnold |
sarah@marrarnoldplanning.com |
Self |
Cincinnati |
Hamilton |
Ohio |
Amy Burns |
April Humphreys |
Signed |
1561 |
2023-04-10 07:35 |
Anonymous (not verified) |
94.188.207.227 |
All season gutter |
Limited Liability Company |
1790 187th street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-10 |
Shane Harold schnittjer |
allseasongutter@outlook.com |
Webster city |
Hamilton |
Iowa |
Andrea Rae schnittjer |
Shane Ethan schnittjer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shane Harold schnittjer |
allseasongutter@outlook.com |
Self |
Webster City |
Hamilton |
Iowa |
Andrea Rae schnittjer |
Shane Ethan schnittjer |
Signed |
1565 |
2023-04-11 09:49 |
Anonymous (not verified) |
94.188.205.177 |
Leonard Moss Roofing |
Proprietorship |
2018 Superior Street, Webster City, Iowa 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-11 |
Leonard Moss |
leonard.moss48@gmail.com |
Webster City |
Hamilton |
Iowa |
Vicky Hahne |
Morgan Jensen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leonard Moss |
leonard.moss48@gmail.com |
Same |
Webster City |
Hamilton |
Iowa |
Vicky Hahne |
Morgan Jensen |
Signed |
1656 |
2023-05-22 11:48 |
Anonymous (not verified) |
94.188.205.169 |
Cesar Arroyo |
Proprietorship |
2207 Lisa Drive, Webster City IA 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Cesar Arroyo |
office.seamlesspros@icloud.com |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Arroyo |
office.seamlesspros@icloud.com |
Self |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
1658 |
2023-05-23 09:56 |
Anonymous (not verified) |
94.188.205.168 |
M&D Webster Construction Inc |
Proprietorship |
1012 Creek Street Webster City IA 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-28 |
David Gomez |
office.seamlesspros@icloud.com |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Gomez |
office.seamlesspros@icloud.com |
Self |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
1832 |
2023-09-08 12:01 |
Anonymous (not verified) |
94.188.207.226 |
GFORCE |
Limited Liability Company |
529 Anderson Street Jewell IA 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-06 |
Scott Andrew Griffin |
G6@q.com |
Jewell |
Hamilton |
Iowa |
Colten Abram Griffin |
Hunter Austin Griffin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colten Abram Griffin |
G6@q.com |
Partner |
Ames |
Story |
Iowa |
Hunter Austin Griffin |
Scott Andrew Griffin |
Signed |
1961 |
2023-12-16 12:22 |
Anonymous (not verified) |
94.188.207.228 |
Randy Hove |
Proprietorship |
2376 370th St. Jewell. Iowa. 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-14 |
Randy Gordon Hove |
mandrhove@gmail.com |
Jewell |
Hamilton |
Iowa |
Ryan Drzycimski |
Casey Westling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy |
mandrhove@gmail.com |
Same |
Same |
Same |
Same |
Same |
Same |
Signed |
2054 |
2024-02-23 10:33 |
Anonymous (not verified) |
94.188.205.175 |
Overgrown Lawn Care & Clean-Up LLC |
Limited Liability Company |
860 Main St. Stanhope, Iowa 50246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-23 |
Shawn David King |
shawndavidking@yahoo.com |
Stanhope |
Hamilton |
Iowa |
Michael Roland King |
Chrisella Ann King |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn David King |
overgrownlawn@yahoo.com |
Is Owner |
Stanhope |
Hamilton |
Iowa |
Michael Roland King |
Chrisella Ann King |
Signed |
240 |
2020-08-23 15:03 |
Anonymous (not verified) |
67.45.96.12 |
Wellik & Sons, LLC |
Limited Liability Company |
1770 HWY 18, Garner, IA 50438 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-23 |
Robert Alan Roths |
robrothsrams@yahoo.com |
Garner |
Hancock |
Iowa |
Ashley S Wellik |
Joshua P. Wellik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Paul Wellik |
wellikandsons@gmail.com |
contractor |
Garner |
Hancock |
Iowa |
Ashley S Wellik |
Joshua P Wellik |
Signed |
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 |
421 |
2021-03-04 07:33 |
Anonymous (not verified) |
97.64.185.162 |
Malek's Lawn & Tree Service |
Proprietorship |
2535 Taft Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-04 |
Shane D. Malek |
Info@Malektreeservice.com |
Garner |
Hancock |
Iowa |
Tod R. Christensen |
Saundra N. Formanek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shane D. Malek |
Info@malektreeservice.com |
Owner |
Garner |
Hancock |
Iowa |
Tod R. Christensen |
Saundra N. Formanek |
Signed |
1016 |
2022-03-29 14:26 |
Anonymous (not verified) |
104.145.202.155 |
S.M.Trucking |
Proprietorship |
3270 Hwy 69 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Steve Miller |
S.M.Trucking52@gmail.com |
3270 Hwy 69 Forest City |
Hancock |
Ia |
Julie Miller |
Amy Picha |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steve Miller |
S.M.Trucking52@gmail.com |
Owner |
3270 Hwy 69 Forest City |
Hancock |
Ia |
Julie Miller |
Amy Picha |
Signed |
2081 |
2024-03-08 10:44 |
Anonymous (not verified) |
94.188.205.167 |
T & S Sandblasting and Painting LLC |
Limited Liability Company |
101 Clinton ST Corwith IA 50430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-08 |
Matthew Tindall |
matt.tindall83@gmail.com |
Corwith |
Hancock |
IA |
Wendy S Jensen |
Jason Bradley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Tindall |
matt.tindall83@gmail.com |
self |
Corwith |
Hancock |
IA |
Wendy S Jensen |
Jason Bradley |
Signed |
2082 |
2024-03-08 10:47 |
Anonymous (not verified) |
94.188.205.176 |
T & S Sandblastin and Painting LLC |
Limited Liability Company |
101 Clinton ST Corwith IA 50430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-08 |
Robert Schissel |
matt.tindall83@gmail.com |
Corwith |
Hancock |
Iowa |
Wendy S Jensen |
Jason Bradley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Schissel |
matt.tindall83@gmail.com |
self |
Corwith |
Hancock |
Iowa |
Wendy S Jensen |
Jason Bradley |
Signed |
657 |
2021-09-27 13:55 |
Anonymous (not verified) |
167.142.136.87 |
Crosser Electric,Inc |
Partnership |
PO Box 204 Eldora, Iowa 50627 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-27 |
Marlyn D Crosser |
vhalvorsen@aol.com |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vicki Halvorsen |
vhalvorsen@aol.com |
Partner andf sec/treasurer |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
658 |
2021-09-27 14:01 |
Anonymous (not verified) |
167.142.136.87 |
Crosser Electric, Inc |
Partnership |
PoBox 204 Eldora, Iowa 50627 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-27 |
Victoria Halvorsen |
vhalvorsen@aol.com |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victoria or Vicki Halvorsen |
vhalvorsen@aol.com |
Partner sec/treasure |
Eldora |
Hardin |
Iowa |
Laura Kramer |
Melissa Sison |
Signed |
1506 |
2023-03-08 15:12 |
Anonymous (not verified) |
94.188.207.226 |
Heritage Towing LLC |
Limited Liability Company |
404 Sherman Ave. Ackley Iowa 50601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-08 |
Jeff Brass |
heritagemotors17@yahoo.com |
Ackley |
Hardin |
Iowa |
Joellen Reynolds |
Linzie Morris |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Brass |
hertiagemotors17@yahoo.com |
Member of LLC |
Ackley |
Hardin |
Iowa |
JoEllen Reynolds |
Linzie Morris |
Signed |
1452 |
2023-02-13 16:49 |
Anonymous (not verified) |
94.188.207.228 |
The Wine Shop, LLC |
Limited Liability Company |
305 Main St, Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2023-02-13 |
Dana Swasand |
danaswasand@rocketmail.com |
Steamboat Rock |
Hardin Co. |
Iowa |
Jay Schares |
Nicole Erickson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Dana Swasand |
danaswasand@rocketmail.com |
Owner/Member |
Steamboat Rock |
Hardin Co. |
Iowa |
Jay Schares |
Nicole Erickson |
Signed |
585 |
2021-07-25 20:07 |
Anonymous (not verified) |
75.162.247.154 |
CJNR Works, LLC |
Limited Liability Company |
17003 Bowdin Crest Drive, Cypress, Texas 77433 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-25 |
Christopher Ridgway |
christopherridgway@gmail.com |
Cypress |
Harris |
TX |
Sophia Ridgway |
Mitchel Monahan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Ridgway |
christopherridgway@gmail.com |
Self |
Cypress |
Harris |
TX |
Sophia Ridgway |
Mitchel Monahan |
Signed |
2168 |
2024-04-22 08:18 |
Anonymous (not verified) |
94.188.207.228 |
Mattson's Floor Covering |
Proprietorship |
2073 Sandy Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Blaine Linn Mattson |
tmatzan99@yahoo.com |
Oquawka |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blaine Mattson |
tmatzan22@yahoo.com |
owner |
Oquawka |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2174 |
2024-04-24 08:22 |
Anonymous (not verified) |
94.188.205.175 |
White's Floorcovering |
Proprietorship |
129 Hillcrest Dr. Biggsville, IL 61418 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Ron White |
hntwhite@frontiernet.net |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron White |
hntwhite@frontiernet.net |
owner |
Biggsville |
Henderson |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
428 |
2021-03-10 12:38 |
Anonymous (not verified) |
66.188.136.150 |
John Smith |
Proprietorship |
2490 E Main St. Lot 41, Plainfield, IN 46168 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
John Smith |
kschumacher@tricorinsurance.com |
Plainfield |
Hendricks |
IN |
Russell Masartis |
Amanda Seeberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Smith |
kschumacher@tricorinsurance.com |
Same |
Plainfield |
Hendricks |
IN |
Russell Masartis |
Amanda Seeberger |
Signed |
761 |
2021-11-22 07:22 |
Anonymous (not verified) |
73.211.163.27 |
James crockett |
Limited Liability Company |
417 easr st south Kewanee il 61443 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-22 |
James crockett |
tattoojec@gmail.com |
Kewanee il |
Henery |
Il |
Tom mcintire |
Colton english |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Hog city construction |
tattoojec@gmail.com |
Self |
Kewanee |
Henery |
Il |
Tom mcintire |
Colon english |
Signed |
131 |
2020-04-27 15:01 |
Anonymous (not verified) |
66.188.136.150 |
Hashem Shawki |
Proprietorship |
8906 Newton Ave. S |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
Hashem Shawki |
kschumacher@tricorinsurance.com |
Bloomington |
Hennepin |
MN |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Hasham Shawki |
kschumacher@tricorinsurance.com |
Same person |
Bloomington |
Hennepin |
MN |
Russell Masartis |
Nancy Wortley |
Signed |
500 |
2021-04-29 13:09 |
Anonymous (not verified) |
204.155.61.217 |
JWJ Home Remodeling LLC |
Limited Liability Company |
16915 Weaver Lake Dr, Maple Grove MN 55311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-29 |
Jackson Janzen |
jacksonjanzen@hailmayday.com |
Maple Grove |
hennepin |
MN |
Ashley Kraft |
DocuSign |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jackson Janzen |
jacksonjanzen@hailmayday.com |
Owner |
Maple Grove |
Hennepin |
MN |
Ashley Kraft |
DocuSign |
Signed |
124 |
2020-04-16 12:07 |
Anonymous (not verified) |
96.3.180.122 |
Gold Rush, LLC |
Limited Liability Company |
1395 130TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-16 |
Jay Christopher Morrow |
jcmorrow2@hotmail.com |
WAYLAND |
Henry |
IAUS |
chad mitchell |
Jonathan Mitchell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gold Rush, LLC |
jcmorrow2@gmail.com |
Self |
WAYLAND |
Henry |
IAUS |
chad mitchell |
Jonathan Mitchell |
Signed |
164 |
2020-05-26 10:30 |
Anonymous (not verified) |
166.182.80.35 |
T.W. Barton Restoration Service |
Proprietorship |
2704 Cass Avenue Mount Pleasant, Iowa 52641 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-26 |
Todd William Barton II |
twbartonrestoration@yahoo.com |
Mount Pleasant |
Henry |
Iowa |
Olivia Grace Barton |
Todd William Barton Sr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd William Barton II |
twbartonrestoration@yahoo.com |
Self |
Mount Pleasant |
Henry |
Iowa |
Olivia Grace Barton |
Todd William Barton Sr. |
Signed |
320 |
2020-11-17 10:08 |
Anonymous (not verified) |
65.103.82.36 |
Brian Behnkendorf dba Dutchmen Services |
Proprietorship |
55 Rose Court West, Geneseo IL 61254 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-13 |
Brian Behnkendorf |
4gbbehnk@gmail.com |
Geneseo |
Henry |
Illinois |
Kayla Artioli |
Eric Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Behnkendorf |
4gbbehnk@gmail.com |
Self |
Geneseo |
Henry |
Illinois |
Kayla Artioli |
Eric Johnson |
Signed |
637 |
2021-09-10 15:15 |
Anonymous (not verified) |
204.155.61.217 |
Duwa Waterproofing LLC |
Limited Liability Company |
1548 150th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-10 |
Stacy Duwa |
duwawaterproofing@gmail.com |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stacy Duwa |
duwawaterproofing@gmail.com |
owner |
Mt Pleasant |
Henry |
Iowa |
Jeffrey Spenner |
Shawn Powell |
Signed |
1260 |
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 |
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 |
1378 |
2022-11-21 15:12 |
Anonymous (not verified) |
136.34.59.85 |
Jake Jones |
Proprietorship |
203 9th Ave. Colona, Il 61241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-21 |
Jake Jones |
jmjones807@gmail.com |
Colona |
Henry |
Illinois |
Jordan Nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Regional Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Daniel Neal |
Signed |
2185 |
2024-04-26 16:46 |
Anonymous (not verified) |
94.188.205.166 |
Jerilyn Horn Kitchen and Bath Design Co. |
Proprietorship |
413 Jefferson St., Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-26 |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
owner |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2208 |
2024-05-07 12:44 |
Anonymous (not verified) |
94.188.205.169 |
Tom Franklin |
Proprietorship |
2353 Salem Road, New London, IA 52645 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-07 |
Thomas Eric Franklin |
68carpetman@gmail.com |
New London |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Eric Franklin |
68carpetman@gmail.com |
owner |
New London |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
34 |
2020-01-10 15:56 |
Anonymous (not verified) |
74.84.121.206 |
Milferd Loewen |
Proprietorship |
6568 Hwy 63, Lime Springs, IA 52155 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-10 |
Milferd Loewen |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel J. Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Milferd Loewen |
darrele@ciains.biz |
self |
Lime Springs |
Howard |
Iowa |
Darrel J. Elsbernd |
Chris Fye |
Signed |
1385 |
2022-12-08 18:45 |
Anonymous (not verified) |
173.26.84.6 |
Fansco LLC |
Limited Liability Company |
620 2 nd Ave SE Cresco IOWA 52136 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-12-08 |
Arif Sheikh |
Sheikha44@yahoo.com |
Cresco |
Howard |
IOWA |
Bibi Sheikh |
Usman Sheikh |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Arif Sheikh |
Sheikha44@yahoo.com |
Relative |
Henderson |
Clark |
Navada |
Bibi Sheikh |
Usman Sheikh |
Signed |
1386 |
2022-12-09 08:35 |
Anonymous (not verified) |
173.26.84.6 |
Fansco LLc DBA Cresco motel |
Limited Liability Company |
620 2 nd Ave SE Cresco IOwa 52136 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-09 |
Arif Sheikh |
Sheikha44@yahoo.com |
Cresco |
Howard |
IOWA |
Bibi Sheikh |
Usman Sheikh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arif Sheikh |
Sheikha44@yahoo.com |
Self |
CRESCO |
Howard |
IOWA |
Bibi Sheikh |
Usman Sheikh |
Signed |
1487 |
2023-02-27 22:12 |
Anonymous (not verified) |
94.188.207.224 |
Panda garden |
Proprietorship |
105 2nd Ave se cresco ia 52136 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-10 |
Jing Chen |
jingchen9968@gmail.com |
Cresco |
Howard |
Iowa |
Leyang Zhou |
Guy Chen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jing Chen |
jingchen9968@gmail.com |
Self |
Cresco |
Howard |
Iowa |
Leyang zhou |
Guy Chen |
Signed |
1489 |
2023-02-28 16:06 |
Anonymous (not verified) |
94.188.207.228 |
Nate's Tractor LLC |
Limited Liability Company |
11939 birch Ave Riceville, IA 50466 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-28 |
Nathan Fox |
nate@natestractor.com |
Riceville |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Fox |
nate@natestractor.com |
Member |
Riceville |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1499 |
2023-03-07 11:21 |
Anonymous (not verified) |
94.188.205.177 |
Ryan Zimmerman |
Proprietorship |
17606 35th St Lime Springs, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-27 |
Ryan Zimmerman |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
1502 |
2023-03-07 12:40 |
Anonymous (not verified) |
94.188.205.177 |
Joseph Martin |
Limited Liability Company |
P O Box 277 Lime Springs, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Joseph Martin |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Al's Roofing LLC |
darrele@ciains.biz |
Member |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chrus Fye |
Signed |
1503 |
2023-03-07 12:45 |
Anonymous (not verified) |
94.188.205.177 |
Al's Roofing LLC |
Limited Liability Company |
P O Box 277 Lime Springs, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
John Martin |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Al's Roofing LLC |
darrele@ciains.biz |
agent |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
1921 |
2023-11-22 12:14 |
Anonymous (not verified) |
94.188.205.177 |
Julie Drtina |
Proprietorship |
Cresco Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-22 |
Julie Drtina |
juliedrtina@hotmail.com |
Cresco |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Julie Drtina |
juliedrtina@hotmail.com |
self |
Cresco |
Howard |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
2007 |
2024-01-29 13:13 |
Anonymous (not verified) |
94.188.205.174 |
Saratoga Seamless Gutters LLC |
Limited Liability Company |
10328 Howard Ave, Lime Springs, IA 52155 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-29 |
Michael Langlais |
saratogaseamlessgutters@gmail.com |
Lime Springs |
Howard |
IA |
Amanda Doty |
Michaela Langlais |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Langlais |
saratogaseamlessgutters@gmail.com |
Owner |
Lime Springs |
Howard |
IA |
Amanda Doty |
Michaela Langlais |
Signed |
278 |
2020-10-09 11:25 |
Anonymous (not verified) |
174.243.82.229 |
ServTwelve7 Consulting, LLC |
Limited Liability Company |
1903 Elmhurst Avenue Humboldt, IA 50548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-09 |
Sonya Satern |
Sonya.satern@ServTwelve7.com |
Humboldt |
Humboldt |
Iowa |
Cindy Vik |
Jill Westre |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sonya Satern |
Sonya.Satern@ServTwelve7.com |
self |
Humboldt |
Humboldt |
Iowa |
Cindy Vik |
Jill Westre |
Signed |
447 |
2021-03-24 14:09 |
Anonymous (not verified) |
208.90.15.53 |
Gabe Saenz, LLC |
Limited Liability Company |
PO Box 53 Humboldt, IA 50548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-24 |
Gabriel Saenz |
gsaenzh@gmail.com |
Humboldt |
Humboldt |
Iowa |
Lance DeWinter |
Cathy Schipull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gabriel Saenz |
gsaenzh@gmail.com |
Owner |
Humboldt |
Humboldt |
Iowa |
Lance DeWinter |
Cathy Schipull |
Signed |
969 |
2022-03-11 16:32 |
Anonymous (not verified) |
74.115.101.41 |
Slaikeu Transport LLC |
Limited Liability Company |
2459 Pine Ave, Humboldt, IA 50548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-11 |
Cole Slaikeu |
cole.slaikeu@gmail.com |
Humboldt |
Humboldt |
IA |
Dale Eng |
Troy Rubel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cole Slaikeu |
cole.slaikeu@gmail.com |
self |
Humboldt |
Humboldt |
IA |
Dale Eng |
Troy Rubel |
Signed |
11 |
2019-12-17 19:46 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Louis I. Maxwell |
brockbrooke2463@yahoo.com |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Louis Maxwell |
brockbrooke2463@yahoo.com |
Owner |
Norwalk |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
12 |
2019-12-17 19:54 |
Anonymous (not verified) |
50.83.188.192 |
B & B Construction |
Proprietorship |
2463 93rd Avenue Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-17 |
Brock A Maxwell |
brock246393@gmail.com |
Des Moines |
IA |
United States |
Hope Winegardner |
Yvonne Ginther |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brock A Maxwell |
brock246393@gmail.com |
Owner |
Des Moines |
POlK |
Iowa |
Yvonne Ginther |
Hope Winegardner |
Signed |
19 |
2019-12-31 16:29 |
Anonymous (not verified) |
172.58.83.45 |
A.M. Tile |
Proprietorship |
3824 122nd st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-31 |
Amar Music |
amarmusic01@gmail.com |
Urbandale |
IA |
United States |
Sefik Music |
Amara Crncevic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amar Music |
amarmusic01@gmail.com |
Owner |
Urbandale |
IA |
United States |
Sefik Music |
Amara Crncevic |
Signed |
20 |
2019-12-31 16:36 |
Anonymous (not verified) |
172.58.83.45 |
A.M. Tile |
Proprietorship |
3824 122nd st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-31 |
Amar Music |
amarmusic01@gmail.com |
Urbandale |
IA |
United States |
Sefik Music |
Amara Crncevic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Omer Okic |
ultimate.exteriors@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Sefik Music |
Amara Crncevic |
Signed |
24 |
2020-01-03 12:41 |
Anonymous (not verified) |
63.152.13.239 |
Eden Plumbing LLC TJ Eden |
Limited Liability Company |
502 Packwaukee Street New Hartford, IA 50660 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-03 |
TJ Eden |
edentj@aol.com |
New Hartford |
IA |
United States |
Ann Robinson |
Nate Schmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PDCM Insurance- Nate Schmidt |
NSCHMIDT@PDCM.COM |
Member |
New Hartford |
Butler |
Iowa |
Ann Robinson |
Nate Schmidt |
Signed |
53 |
2020-02-06 11:09 |
Anonymous (not verified) |
65.100.22.228 |
Bostian Captioning Service, Inc. |
Proprietorship |
712 8th Avenue NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-06 |
Dana Bostian |
danabostian@msn.com |
Oelwein |
IA |
United States |
Lynne Koch |
Billie Winters |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dana Bostian |
danabostian@msn.com |
President of Proprietorship |
Oelwein |
IA |
United States |
Lynne Koch |
Billie Winters |
Signed |
98 |
2020-03-23 15:07 |
Anonymous (not verified) |
65.120.236.250 |
Cross Roads Logistics, LLC |
Limited Liability Company |
3103 21st St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-23 |
Mark Alan Cross |
rcreek2016@gmail.com |
Davenport |
IA |
IA |
Lori Ann Cross |
Barbara A Deering |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Alan Cross |
rcreek2016@gmail.com |
President/Owner |
Davenport |
IA |
IA |
Lori Ann Cross |
Barbara A Deering |
Signed |
104 |
2020-03-26 19:00 |
Anonymous (not verified) |
173.189.167.170 |
MCB CONSTRUCTION INC |
Limited Liability Company |
3484 VERMONT ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-26 |
michael wade bethards |
mwbethards@yahoo.com |
NEW VIRGINIA |
IA |
IA |
noel isaac |
alice lohmann |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
mike bethards |
mwbethards@yahoo.com |
owner |
New Virginia |
warren |
IA |
noel isaac |
alice lohmann |
Signed |
132 |
2020-04-27 17:26 |
Anonymous (not verified) |
73.94.97.93 |
Kota Construction |
Limited Liability Company |
52 SE Pembrooke Ln |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-27 |
Dakota Beaulieu |
cody.b@buildwithkota.com |
Waukee |
IA |
United States |
Kyli Torkelson |
Koray Furrow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dakota Beaulieu |
cody.b@buildwithkota.com |
Self |
Waukee |
Dallas |
Iowa |
Kyli Torkelson |
Koray Furrow |
Signed |
146 |
2020-05-01 05:34 |
Anonymous (not verified) |
174.217.5.175 |
Five Nail Services |
Limited Liability Company |
32379 162nd Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-01 |
Ralph Chiodo |
rchiodo2@gmail.com |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ralph Chiodo |
rchiodo2@gmail.com |
Self |
Woodward |
IA |
United States |
Ralph Chiodo |
Rebecca Chiodo |
Signed |
155 |
2020-05-12 17:03 |
Anonymous (not verified) |
173.17.184.241 |
Shelly Whalen |
Proprietorship |
1625 Darby Dr Waterloo IA 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-12 |
Shelly Whalen |
swhalen90@hotmail.com |
Waterloo |
IA |
United States |
Taylor Whalen |
Todd Gerleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shelly Whalen |
swhalen90@hotmail.com |
self employed |
Waterloo |
IA |
United States |
Taylor Whalen |
Todd Gerleman |
Signed |
182 |
2020-06-11 14:18 |
Anonymous (not verified) |
173.29.64.73 |
Diamond Builders of Davenport INC |
Proprietorship |
14358 275th St, Long grove, IA 52756 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-11 |
Paula Woods |
paulawoods@diamond-builders.com |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tyler Green |
tyler@porterinsuranceinc.com |
Insurance Agent |
Long Grove |
IA |
United States |
Colin Woods |
Joe Roozeboom |
Signed |
183 |
2020-06-12 08:23 |
Anonymous (not verified) |
107.77.173.7 |
A&W Marble & Tile |
Proprietorship |
5624 Sw 5Th Pl |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Wayne A Yergy |
wyergy@gmail.com |
Des Moines |
IA |
United States |
Michael L Smith |
Guy B Chaney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wayne Yergy |
wyergy@gmail.com |
Self |
Des Moines |
IA |
United States |
Michael L Smith |
Guy B Chaney |
Signed |
187 |
2020-06-15 11:55 |
Anonymous (not verified) |
67.60.42.173 |
SANDS CONSTRUCTION LLC |
Limited Liability Company |
3812 Sioux River Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-06-15 |
Ryan Sands |
rn_sands@hotmail.com |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ryan Sands |
rn_sands@hotmail.com |
self/ Owner/ Operator |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
188 |
2020-06-15 11:55 |
Anonymous (not verified) |
67.60.42.173 |
SANDS CONSTRUCTION LLC |
Limited Liability Company |
3812 Sioux River Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-06-15 |
Ryan Sands |
rn_sands@hotmail.com |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ryan Sands |
rn_sands@hotmail.com |
self/ Owner/ Operator |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
189 |
2020-06-16 16:24 |
Anonymous (not verified) |
173.28.58.2 |
Perry Engel |
Proprietorship |
140 2nd Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Perry Engel |
HRSolutionsContracting@gmail.com |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Perry Engel |
HRSolutionsContracting@gmail.com |
Self |
Oelwein |
IA |
United States |
Danette Hager |
Tosha Medina |
Signed |
212 |
2020-07-20 16:43 |
Anonymous (not verified) |
97.64.164.30 |
Bernard L. Gradoville D.D.S. |
Proprietorship |
2800 Ingersoll Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-20 |
Bernard Gradoville |
bgradoville@ingersollfamilydentistry.com |
Des Moines |
IA |
United States |
Tricia Wilson |
Jack Gradoville |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bernard Gradoville |
bgradoville@ingersollfamilydentistry.com |
self |
Des Moines |
IA |
United States |
Tricia Wilson |
Jack Gradoville |
Signed |
258 |
2020-09-15 13:14 |
Anonymous (not verified) |
50.83.182.140 |
Moyer Painting |
Proprietorship |
934 Norwood Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-15 |
jerome Moyer |
moyer_painting@live.com |
Norwalk |
IA |
United States |
Sally Moyer |
Adam Adams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jerome b moyer |
moyer_painting@live.com |
Self |
norwalk |
IA |
United States |
sally moyer |
Adam Adams |
Signed |
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 |
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 |
293 |
2020-10-28 06:58 |
Anonymous (not verified) |
173.189.165.102 |
Boettcher Construction |
Proprietorship |
PO Box 482, 843 West Business 30 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-28 |
otto p boettcher |
obc32@live.com |
Lisbon |
IA |
iowa |
Barb Boettcher |
Barb Boettcher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
otto p boettcher |
obc32@live.com |
same person |
Lisbon |
IA |
iowa |
Barb Boettcher |
Barb Boettcher |
Signed |
330 |
2020-12-03 08:11 |
Anonymous (not verified) |
208.126.61.46 |
Hometown Comfort Heating & Cooling, LLC. |
Limited Liability Company |
1855 280th St. Webster City, Ia. 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-03 |
Mason Ormesher |
hometowncomfortia@gmail.com |
Webster City |
IA |
United States |
Kylee Ormesher |
Karen Ostrem |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Ormesher |
hometowncomfortia@gmail.com |
Owner |
Webster City |
Hamilton |
Iowa |
Kylee Ormesher |
Karen Ostem |
Signed |
334 |
2020-12-07 12:38 |
Anonymous (not verified) |
173.19.190.160 |
Broadband Installations of Iowa LLC |
Limited Liability Company |
P.O. Box 728 Carroll, IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-07 |
Charles Wood |
cwood.bband@outlook.com |
CEDAR RAPIDS |
IA |
IA |
Eva Wood |
Tamara Wood |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Skyla Siech |
skylabbi@outlook.com |
Offcie Manager |
Ely |
Linn |
Iowa |
Melvin Harter |
Eddie Bell |
Signed |
347 |
2020-12-31 13:44 |
Anonymous (not verified) |
66.129.217.166 |
Issis Melissa Nunez |
Proprietorship |
2128 S Riverside Dr. Trl 57, Iowa City, IA 52246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
Issis Melissa Nunez |
tonypauljohnson@yahoo.com |
Iowa City |
IA |
United States |
Anthony Johnson |
Olvin Lanza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Issis Melissa Nunez |
tonypauljohnson@yahoo.com |
Owner |
Iowa City |
IA |
United States |
Anthony Johnson |
Olvin Lanza |
Signed |
348 |
2020-12-31 14:09 |
Anonymous (not verified) |
66.129.217.166 |
Premier Plus LLC |
Limited Liability Company |
1930 St Andrews Crt NE, Suite A, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
Cerby Newton |
tonypauljohnson@yahoo.com |
Cedar Rapids |
IA |
United States |
Olvin Lanza |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cerby Newton |
tonypauljohnson@yahoo.com |
Owner |
Cedar Rapids |
IA |
United States |
Anthony Johnson |
Olvin Lanza |
Signed |
360 |
2021-01-12 12:08 |
Anonymous (not verified) |
75.162.189.102 |
Super Green Plus Llc |
Limited Liability Company |
3020 SE 5th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-12 |
Damon Berry |
theatvfan@gmail.com |
Des Moines |
IA |
United States |
Naki Brown |
Nakima Brown |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Super Green Plus |
theatvfan@gmail.com |
owner |
Des Moines |
IA |
United States |
Naki Brown |
Nakima Brown |
Signed |
366 |
2021-01-18 18:32 |
Anonymous (not verified) |
75.162.57.214 |
Affordable Exteriors, LLC |
Limited Liability Company |
802 east COUNTY LINE RD #57 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-18 |
Destiny Moses |
Info@mktdsm.com |
DES MOINES |
IA |
United States |
Miguel Angel Garcia Ramirez |
Nelly Bekker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Destiny Moses |
Info@mktdsm.com |
owner |
DES MOINES |
IA |
United States |
Miguel Garcia |
Nellie Bekker |
Signed |
367 |
2021-01-21 14:18 |
Anonymous (not verified) |
107.117.168.117 |
1105 Wade St |
Proprietorship |
1105 WADE ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-03 |
Jose J Castillo |
Jonathancas782@gmail.com |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jose J Castillo |
Jonathancas782@gmail.com |
Owner |
DES MOINES |
IA |
United States |
Jose gaytan |
Ruben lopez |
Signed |
378 |
2021-01-29 11:43 |
Anonymous (not verified) |
50.82.21.136 |
GRAPHIX MASTERS |
Limited Liability Company |
420 Hamilton St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-01-29 |
Klayton Karl Kirkpatrick |
klay@graphixmasters.us |
Ottumwa |
IA |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Klayton Kirkpatrick |
klay@graphixmasters.us |
Same |
Ottumwa |
Iowa |
United States |
Brian Wilson |
Aimee Kirkpatrick |
Signed |
381 |
2021-02-02 12:46 |
Anonymous (not verified) |
167.142.150.21 |
T and A Transfer, LLC. |
Limited Liability Company |
3330 340th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-02 |
Todd L Ahrenholtz |
todd.ahrenholtz123@gmail.com |
Manilla |
IA |
IA |
Angela Ahrenholtz |
Angela Ahrenholtz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Todd L Ahrenholtz |
todd.ahrenholtz123@gmail.com |
owner |
Manilla |
Iowa |
Iowa |
Angela Ahrenholtz |
Angela Ahrenholtz |
Signed |
464 |
2021-04-07 22:15 |
Anonymous (not verified) |
173.18.251.105 |
TEMPLEMAN LAWN CARE AND SNOW REMOVAL |
Proprietorship |
1612 Lomas Circle |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-07 |
TIM LEE Templeman |
nancytempleman@gmail.com |
Atlantic |
IA |
United States |
TARA JESSEN |
ALFRED WEDE |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
CULLEN AND ASSOCIATES |
tammy@cullenins.com |
Insurance agent |
Atlantic |
Cass |
Iowa |
Tara Jessen |
Alfred Wede |
Signed |
467 |
2021-04-10 12:21 |
Anonymous (not verified) |
24.252.54.168 |
Dave and Nancy Preucil Inc. |
Proprietorship |
13585 Clearview Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-10 |
Domenico Zurini II |
davesspeedwaydz@gmail.com |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbi Zurini |
bzurini@gmail.com |
Wife |
Council Bluffs |
IA |
United States |
Irven Saar II |
Jeffrey Hanke |
Signed |
470 |
2021-04-13 09:34 |
Anonymous (not verified) |
173.21.135.56 |
JNZ Recruiting LLC |
Limited Liability Company |
703 Washington St. Williamsburg, IA 52361 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-04-07 |
Javier Nevarez |
amanda@burginsuranceagency.com |
Williamsburg |
IA |
IA |
Amanda Clubb |
Bradley Schaefer |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Javier Nevarez |
amanda@burginsuranceagency.com |
Self |
Williamsburg |
Iowa |
Iowa |
Amanda Clubb |
Bradley Schaefer |
Signed |
495 |
2021-04-23 11:26 |
Anonymous (not verified) |
98.22.221.1 |
T & S Industries Inc |
Partnership |
200 West Jefferson |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-23 |
Tim Hunter |
tands@iowatelecom.net |
Afton |
IA |
IA |
Cindy R Harper |
Richard Mordock |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travelers Insurance |
lisa@allplansins.com |
agent |
Afton |
IA |
IA |
Cindy R Harper |
Richard Mordock |
Signed |
511 |
2021-05-10 17:53 |
Anonymous (not verified) |
173.24.231.27 |
QSC Snow Removal |
Proprietorship |
1211 Carroll Boone IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Vincent A Kaylor |
phenox32@gmail.com |
Boone |
IA |
United States |
Lori Harvey |
Doug Robertson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Vincent A Kaylor |
phenox32@gmail.com |
self |
Boone |
IA |
United States |
Lori Harvey |
Doug Robertson |
Signed |
531 |
2021-05-26 13:02 |
Anonymous (not verified) |
75.162.156.185 |
Xander Wessels |
Limited Liability Company |
719 10TH ST NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-26 |
Alexander Wessels |
kprepair@outlook.com |
MASON CITY |
IA |
IA |
Dusty Howe |
Sadie Lonning |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dusty Howe |
dusty.mcelectric@gmail.com |
Sub Contractor |
Mason City |
Cerro Gordo |
Iowa |
Dusty Howe |
Sadie Lonning |
Signed |
563 |
2021-07-08 12:16 |
Anonymous (not verified) |
173.17.250.209 |
Forest Avenue Outreach |
Limited Liability Company |
1600 6th Ave DSM IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-08 |
Maya Bromolson |
maya@goodvibesmovement.org |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maya Bromolson |
maya@goodvibesmovement.org |
Executive Director |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
565 |
2021-07-08 13:42 |
Anonymous (not verified) |
173.25.132.255 |
Communications Construction Services LLC |
Limited Liability Company |
1315 East 38th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-08 |
John McCann Jr |
communicationconstructionllc@gmail.com |
Des Moines |
IA |
United States |
Laura McCann |
David Garza |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Laura McCann |
communicationconstructionllc@gmail.com |
spouse |
Des Moines |
IA |
United States |
John J McCann Jr |
David Christopher Garza III |
Signed |
569 |
2021-07-09 12:18 |
Anonymous (not verified) |
173.17.250.209 |
Forest Ave Outreach dba Good Vibes Movement |
Limited Liability Company |
1600 6th Ave DSM IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-09 |
Ben Spellman |
ben@goodvibesmovement.org |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maya Bromolson |
maya@goodvibesmovement.org |
Executive Director |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
591 |
2021-07-29 16:42 |
Anonymous (not verified) |
138.43.237.95 |
Choice Ag Services INC |
Proprietorship |
1841 Firefly Rd, Manchester, IA 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-29 |
Dustin Fessler |
dustin@choiceagservices.com |
Manchester |
IA |
United States |
Josh Soppe |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Fessler |
dustin@choiceagservices.com |
Owner |
Manchester |
Delaware |
Iowa |
Josh Soppe |
Adam Reth |
Signed |
592 |
2021-07-29 16:44 |
Anonymous (not verified) |
138.43.237.95 |
Choice Ag Services INC |
Proprietorship |
1841 Firefly Rd, Manchester, IA 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-29 |
Adam Reth |
adam@choiceagservices.com |
Manchester |
IA |
United States |
Josh Soppe |
Adam Reth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Reth |
adam@choiceagservices.com |
Owner |
Manchester |
Delaware |
Iowa |
Josh Soppe |
Dustin Fessler |
Signed |
602 |
2021-08-13 22:49 |
Anonymous (not verified) |
208.38.230.125 |
Granite & More |
Limited Liability Company |
4730, Tremont Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-14 |
Jin Chen |
clteam563@gmail.com |
Davenport |
IA |
United States |
Jin Chen |
Betty Song |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Hong Le |
clteam563@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Jin Chen |
Betty Song |
Signed |
603 |
2021-08-14 09:39 |
Anonymous (not verified) |
173.20.168.51 |
Leaf Filter |
Proprietorship |
3060 Southeast Grimes Boulevard |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-08-14 |
Francisco Salgado |
fsalgado1989@gmail.com |
Perry |
IA |
United States |
Wendy Asturias |
Susana Romero |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Leaf Filter |
macosta@leafhome.com |
none |
Grimes |
Polk |
Iowa |
Wendy Asturias |
Susana Romero |
Signed |
604 |
2021-08-14 11:18 |
Anonymous (not verified) |
69.54.119.134 |
Robert Curry |
Limited Liability Company |
10759 S 96th Ave W Prairie City IA 50228 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-14 |
Bob Curry |
Gardengal4205@gmail.com |
Prairie City |
IA |
United States |
Megan Irwin |
Rob Irwin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Curry |
Gardengal4205@gmail.com |
Self |
Prairie City |
IA |
United States |
Megan Irwin |
Rob Irwin |
Signed |
623 |
2021-08-30 15:03 |
Anonymous (not verified) |
174.198.77.231 |
Joe Dawson |
Proprietorship |
1088, Dogwood Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-30 |
Joe R Dawson |
joerdawson@gmail.com |
Coon Rapids |
IA |
United States |
Linda Doran |
Megan Specht |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Joe R Dawson |
joerdawson@gmail.com |
Owner |
Coon Rapids |
IA |
United States |
Linda Doran |
Megan Specht |
Signed |
650 |
2021-09-22 20:46 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services |
Limited Liability Company |
6285 n 67 ave w baxter iowa 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
owner |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
651 |
2021-09-22 21:05 |
Anonymous (not verified) |
174.198.68.116 |
Freedom field services LLC |
Limited Liability Company |
6285 n 67 ave w. BAXTER IOWA 50028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
joseph robert cunningham jr |
joecunningham1966@protonmail.com |
owner |
Baxter |
IA |
United States |
chelsey a cunningham |
jordan r cunningham |
Signed |
653 |
2021-09-23 15:03 |
Anonymous (not verified) |
72.46.189.33 |
Feldkamp Farms Inc |
Partnership |
5382 170th St Sibley IA 51249 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-23 |
Harold P Feldkamp |
joan@ellerbroekandassociates.com |
Sibley |
IA |
United States |
Wade Ellerbroek Jr |
Joan Wallace |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Wade Ellerbroek Jr |
WADE@ELLERBROEKANDASSOCIATES.COM |
Agent only |
Sibley |
IA |
United States |
Wade Ellerbroek Jr |
Joan Wallace |
Signed |
659 |
2021-09-28 11:02 |
Anonymous (not verified) |
172.58.83.48 |
Sean Goodwin |
Limited Liability Company |
8843 primrose lane Clive IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-28 |
Sean Goodwin |
simplemanmx@gmail.com |
Clive |
IA |
United States |
Kaitlyn meier |
Tina meier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Goodwin |
simplemanmx@gmail.com |
Self |
Clive |
Polk |
Iowa |
Kaitlyn meier |
Tina meier |
Signed |
667 |
2021-10-11 19:33 |
Anonymous (not verified) |
104.166.240.24 |
FS Custom Flooring |
Limited Liability Company |
5729 NW 92nd street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-11 |
Filip Sakanovic |
filip@fscustomflooring.com |
Johnston |
IA |
United States |
Senad Sakanovic |
Filip Sakanovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
FS Tiling and Ceramics |
filip@fscustomflooring.com |
N/A |
Johnston |
IA |
United States |
Senad Sakanovic |
Filip Sakanovic |
Signed |
677 |
2021-10-18 11:09 |
Anonymous (not verified) |
69.18.40.109 |
MR&E,llc |
Limited Liability Company |
2501 Summer St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-18 |
Marcie R Gaylord |
avisburlington@hotmail.com |
Fort Madison |
IA |
United States |
Kim Delap |
Teri Coleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcie Bollin Gaylord |
avisburlington@hotmail.com |
President |
FORT MADISON |
Lee |
Iowa |
Kim Delap |
Teri Coleman |
Signed |
678 |
2021-10-18 11:26 |
Anonymous (not verified) |
69.18.40.109 |
MR&E,llc |
Limited Liability Company |
2501 Summer St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-18 |
Linda Hunter |
whitandpayt@gmail.com |
Burlington |
IA |
United States |
Kim Delap |
Teri Coleman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcie Bollin Gaylord |
avisburlington@hotmail.com |
President |
FORT MADISON |
IA |
United States |
Kim Delap |
Teri Coleman |
Signed |
680 |
2021-10-18 13:58 |
Anonymous (not verified) |
166.181.86.88 |
Gerald Jerome |
Proprietorship |
2668 Wapsi Ridge Dr. Walker, IA 52352 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-18 |
Gerald Jerome |
geraldjerome373@ymail.com |
Walker |
IA |
United States |
Benjamin J Barkalow |
James M. Barkalow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerald Jerome |
geraldjerome373@ymail.com |
Self employed |
Walker |
Linn |
Iowa |
Benjamin J Barkalow |
James M Barkalow |
Signed |
683 |
2021-10-20 09:39 |
Anonymous (not verified) |
173.23.253.122 |
Superior Floors |
Limited Liability Company |
704 41st Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-20 |
Ron Shannon |
ronshannon3831@gmail.com |
West Des Moines |
IA |
United States |
Virginia Shannon |
Virginia Shannon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Shannon |
ronshannon3831@gmail.com |
Self |
West Des Moines |
IA |
United States |
Virginia Shannon |
Virginia Shannon |
Signed |
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 |
696 |
2021-10-28 10:33 |
Anonymous (not verified) |
173.18.85.215 |
Saunders Construction |
Proprietorship |
7304 SW 14th St Des Moines Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-28 |
Charles A Saunders |
charlessaunders901@gmail.com |
Des Moines |
IA |
United States |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Saunders |
charlessaunders901@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Ramona Mitchell |
Rasheedah Gasaway |
Signed |
702 |
2021-11-01 09:23 |
Anonymous (not verified) |
173.28.195.56 |
Garcia Snow Removal |
Limited Liability Company |
213 E 7th Street, West Liberty, Iowa 52776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-01 |
Benji A Garcia |
garciabenji23@gmail.com |
West Liberty |
IA |
Norway |
Luis Ordenana-Choez |
Vicente Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Benji Garcia |
garciabenji23@gmail.com |
Member |
West Liberty |
Muscatine |
Iowa |
Luis Ordenana-Choez |
Vicente Garcia |
Signed |
752 |
2021-11-17 08:22 |
Anonymous (not verified) |
166.181.82.81 |
Michael sprout |
Limited Liability Company |
1208 N THORNWOOD AVE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-14 |
Michael Sprout |
1293newhome@gmail.com |
Davenport |
IA |
IA |
Mike smith |
Doug palmer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Sprout |
1293newhome@gmail.com |
Geico |
Davenport |
IA |
IA |
Mike smith |
Doug palmer |
Signed |
760 |
2021-11-21 16:31 |
Anonymous (not verified) |
107.77.206.216 |
Jacob Odean |
Limited Liability Company |
6634 Lorton CT. Davenport IA 52807 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-21 |
Jacob James Odean |
jodean5725@gmail.com |
DAVENPORT |
IA |
United States |
James Odean |
Vickie Odean |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob James Odean |
jodean5725@gmail.com |
Same |
DAVENPORT |
SCOTT |
United States |
James Odean |
Vickie Odean |
Signed |
773 |
2021-11-24 14:48 |
Anonymous (not verified) |
24.149.18.237 |
The Ragged Edge Art Bar and Gallery |
Limited Liability Company |
504 Bluff Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-24 |
Kendra Wohlert |
kwohlert43@gmail.com |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kendra Wohlert |
kwohlert43@gmail.com |
self |
CEDAR FALLS |
IA |
United States |
Theresa Johnson |
Danette Priebe |
Signed |
779 |
2021-12-06 10:43 |
Anonymous (not verified) |
172.83.21.144 |
Munn Enterprises LLC |
Limited Liability Company |
118 14th Avenue South |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-06 |
Douglas A Munn |
munnent1328@gmail.com |
Clear lake |
IA |
IA |
Troy Thomas Munn |
Marjorie Marie Munn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Troy Munn |
Troy@munnentllc.com |
Owner |
Clear Lake |
Cerro Gordo |
Iowa |
Troy Thomas Munn |
Marjorie Marie Munn |
Signed |
782 |
2021-12-08 10:11 |
Anonymous (not verified) |
173.21.158.248 |
Barry Duncan |
Proprietorship |
2020 S.E. Four Seasons Dr., Ankeny IA 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-08 |
BARRY DUNCAN |
bduncan1452@gmail.com |
Ankeny |
IA |
Iowa |
Kathy Belieu |
Summer Belieu-Slemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BARRY DUNCAN |
bduncan1452@gmail.com |
Self |
Ankeny |
Polk |
Iowa |
Kathy Belieu |
Summer Belieu-Slemp |
Signed |
784 |
2021-12-09 09:03 |
Anonymous (not verified) |
97.64.139.42 |
JZ INC |
Limited Liability Company |
2509 Ne 10th CT Grimes Iowa 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-08 |
James Scott Zastrow |
Zastrow74@gmail.com |
Grimes |
IA |
United States |
NIcole Zastrow |
Kevan Wiggins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James scott Zastrow |
loffredon@aol.com |
Self |
Grimes |
IA |
United States |
nicole zastrow |
Kevan wiggins |
Signed |
795 |
2021-12-15 07:47 |
Anonymous (not verified) |
173.22.84.26 |
LAMPE APPLIANCE SERVICE, Inc |
Proprietorship |
210 29TH ST NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-15 |
Douglas James Lampe |
lampeappliance@gmail.com |
CEDAR RAPIDS |
IA |
IA |
John Kenneth Lampe |
Kenneth Roman Lampe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas James Lampe |
lampeappliance@gmail.com |
Vice President |
Cedar Rapids |
Linn |
Iowa |
John Kenneth Lampe |
Kenneth Roman Lampe |
Signed |
815 |
2021-12-28 12:29 |
Anonymous (not verified) |
173.29.239.122 |
Comtek, Inc. |
Proprietorship |
3702 NW 13th St. Ankeny, Iowa 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-28 |
Micheal D. Qualley |
mqcomtek@gmail.com |
ANKENY |
IA |
United States |
Jacque Blackman |
Jeffery Keipper |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacque Blackman |
jblackman@grimesfinancialgroup.com |
client |
Grimes |
Polk |
Iowa |
Jacque Blackman |
Jeffery Keipper |
Signed |
825 |
2022-01-06 21:02 |
Anonymous (not verified) |
174.213.145.18 |
Two Brothers Tile llc |
Proprietorship |
1244 72nd St Windsor heights ia 50324 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-06 |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Senahid Mujkanovic |
xbosanacbax17@gmail.com |
Owner |
Windsor Heights |
IA |
United States |
Ramiza kadric |
Senad mujkanovic |
Signed |
842 |
2022-01-17 16:29 |
Anonymous (not verified) |
172.58.87.164 |
The Green Boys |
Limited Liability Company |
55 Southeast Windfield Parkway |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-17 |
Emilio Belismelis |
emiliobelismelis87@gmail.com |
Waukee |
IA |
United States |
Lorena Belismelis |
Lorena Belismelis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
The Green Boys |
emiliobelismelis87@gmail.com |
Owner |
Waukee |
IA |
United States |
Emilo Belismelis |
Maria Belismelis |
Signed |
845 |
2022-01-20 09:06 |
Anonymous (not verified) |
208.126.69.10 |
KenX Pest Control |
Limited Liability Company |
350 2nd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-20 |
Ken YARRINGTON |
kenxpestcontrol@hotmail.com |
Truro |
IA |
IA |
James Gage |
Kent Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kenneth Charles Yarrington |
kenxpestcontrol@hotmal.com |
Myself |
Truro |
IA |
IA |
James Gage |
Kent Smith |
Signed |
854 |
2022-01-24 19:59 |
Anonymous (not verified) |
217.180.228.216 |
Hansen Installations |
Limited Liability Company |
109 NW Calista Ct. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-24 |
Brian D Hansen |
bdhansen33@gmail.com |
Grimes |
IA |
United States |
Laurie Mills |
Jaiden Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian D Hansen |
bdhansen33@gmail.com |
Self |
Grimes |
IA |
United States |
Laurie Mills |
Jaiden Nelson |
Signed |
866 |
2022-01-27 19:15 |
Anonymous (not verified) |
199.66.15.25 |
Greg Cheno Services LLC |
Limited Liability Company |
203 N H St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Gregory Chenoweth |
gregcheno@gmail.com |
Indianola |
IA |
United States |
Rebecca Sue Abbott |
Gregory Blair Abbott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gregory J. Chenoweth |
gregcheno@gmail.com |
Same |
Indianola |
Warren |
Iowa |
Rebecca Sue Abbott |
Gregory Blair Abbott |
Signed |
871 |
2022-01-29 15:43 |
Anonymous (not verified) |
173.31.116.134 |
West cleaning |
Proprietorship |
8925 Cascade Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-29 |
Fata Omerovic |
fataomerovic@msn.com |
West Des Moines |
IA |
Iowa |
Semir Omerovic |
Samir Omerovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fata Omerovic |
fataomerovic@msn.com |
Same person |
West Des Moines |
IA |
Iowa |
Semir Omerovic |
Samir Omerovic |
Signed |
879 |
2022-01-31 14:26 |
Anonymous (not verified) |
173.27.146.201 |
Premier Window Cleaning LLC |
Limited Liability Company |
420 E GRANGER AVE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-31 |
Frank Viola |
premierofiowa@gmail.com |
DES MOINES |
IA |
United States |
Ron Reynolds |
Chris Greco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Frank Viola |
premierofiowa@gmail.com |
my self |
DES MOINES |
IA |
United States |
Ron Reynolds |
Chris Greco |
Signed |
897 |
2022-02-04 15:15 |
Anonymous (not verified) |
163.116.133.119 |
Schauf Investments LLC |
Limited Liability Company |
3465 Vermont Street, New Virginia, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-04 |
Maxwell Schauf |
max.schauf@gmail.com |
New Virginia |
IA |
United States |
Krisha Schauf |
Robin Schauf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maxwell Schauf |
max.schauf@gmail.com |
General Member |
New Virginia |
IA |
United States |
Krisha Schauf |
Robin Schauf |
Signed |
899 |
2022-02-05 13:35 |
Anonymous (not verified) |
67.3.142.168 |
Hart Holland LLC |
Limited Liability Company |
526 N 13th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-05 |
Elizabeth Holland |
ehollanddvm@gmail.com |
Adel |
IA |
IA |
Jon Hart |
Mary Hart |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elizabeth Holland |
ehollanddvm@gmail.com |
self |
Adel |
IA |
IA |
Jon Hart |
Mary Hart |
Signed |
900 |
2022-02-05 13:36 |
Anonymous (not verified) |
67.3.142.168 |
Iconic Properties LLC |
Limited Liability Company |
526 N 13th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-05 |
Elizabeth Holland |
ehollanddvm@gmail.com |
Adel |
IA |
IA |
Jon Hart |
Mary Hart |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elizabeth Holland |
ehollanddvm@gmail.com |
self |
Adel |
IA |
IA |
Jon Hart |
Mary Hart |
Signed |
951 |
2022-03-05 07:53 |
Anonymous (not verified) |
207.32.3.98 |
Larson Transport Systems |
Limited Liability Company |
3055 Maple Ave. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-05 |
Spencer Larson |
spenlarson@gmail.com |
Forest City |
IA |
United States |
Mike Larson |
Sandy Larson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Larson |
spenlarson@gmail.com |
owner |
Forest City |
IA |
United States |
Mike Laron |
Sandy Larson |
Signed |
966 |
2022-03-11 10:04 |
Anonymous (not verified) |
173.19.189.168 |
Steger Siding & Construction |
Limited Liability Company |
1020 25th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-11 |
Jared Steger |
jared.steger@gmail.com |
Marion |
IA |
United States |
Jared Steger |
Jared Steger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Steger |
jared.steger@gmail.com |
self |
Marion |
IA |
United States |
Jared Steger |
Jared Steger |
Signed |
988 |
2022-03-21 10:40 |
Anonymous (not verified) |
173.27.156.183 |
JABS Construction/Finish |
Limited Liability Company |
543 10th Ave. S. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-20 |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Clinton |
IA |
United States |
N/A |
N/a |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Owner |
Clinton |
IA |
United States |
N/A |
N/A |
Signed |
989 |
2022-03-21 10:40 |
Anonymous (not verified) |
173.27.156.183 |
JABS Construction/Finish |
Limited Liability Company |
543 10th Ave. S. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-20 |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Clinton |
IA |
United States |
N/A |
N/a |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Owner |
Clinton |
IA |
United States |
N/A |
N/A |
Signed |
1003 |
2022-03-23 13:06 |
Anonymous (not verified) |
24.149.3.190 |
Thomas Wedmore |
Proprietorship |
200 State St, Ste 202G, Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-23 |
Thomas Wedmore |
twedmore@phillipsstafford.com |
Cedar Falls |
IA |
United States |
Bradley Phillips |
Joshua Stafford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Wedmore |
twedmore@phillipsstafford.com |
Self |
Reinbeck |
Grundy |
IA |
Bradley Phillips |
Joshua Stafford |
Signed |
1020 |
2022-03-29 16:53 |
Anonymous (not verified) |
207.32.60.144 |
J.A. Dahlhauser, Ltd. |
Proprietorship |
1741 Hwy. 7 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Jaylin A. Dahlhauser |
jaydahlhauser@gmail.com |
Newell |
IA |
United States |
Matthew McClellan |
Gracelin R. Dahlhauser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaylin A. DAhlhauser |
jaydahlhauser@gmail.com |
Owner |
Newell |
IA |
United States |
Matthew McClellan |
Gracelin R. Dahlhauser |
Signed |
1034 |
2022-04-05 11:43 |
Anonymous (not verified) |
75.162.133.214 |
Riftworks Wood Manufactory |
Proprietorship |
3807 Adams Ave, Des moines, Iowa 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
Bryan Siever |
bryan@siever.us |
Des Moines |
IA |
United States |
Cakeb Payne |
Tyler Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryan siever |
bryan@siever.us |
Business owner |
Des Moines |
IA |
United States |
Caleb Payne |
Tyler Anderson |
Signed |
1036 |
2022-04-06 10:22 |
Anonymous (not verified) |
67.212.111.166 |
Precision Painting |
Proprietorship |
507 Broad Street, Reinbeck Iowa 50669 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-06 |
Dan Bowser |
dbowser.precision.painting@gmail.com |
Reinbeck |
IA |
United States |
Kari Houle |
Steve Swanson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
CEDAR FALLS |
IA |
United States |
Kari Houle |
Steve Swanson |
Signed |
1038 |
2022-04-11 09:43 |
Anonymous (not verified) |
173.27.156.183 |
JABS Construction/Finish |
Limited Liability Company |
543 10th Ave. S. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-11 |
Roberto John Henrickson |
henricksonroberto10@gmail.com |
Clinton |
IA |
United States |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay County |
Missouri |
Roberto J Henrickson |
Cody Dunbar |
Signed |
1049 |
2022-04-14 14:29 |
Anonymous (not verified) |
72.13.27.253 |
Gudenkauf Underground llc |
Limited Liability Company |
1840 275th St Manchester Ia., 52057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Terry Gudenkauf |
tgudenkauf@yousq.net |
Manchester |
IA |
United States |
Lisa Gudenkauf |
Tim Gudenkauf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Gudenkauf |
tgudenkauf@yousq.net |
Self |
Manchester |
IA |
United States |
Lisa Gudenkauf |
Tim Gudenkauf |
Signed |
1057 |
2022-04-18 12:53 |
Anonymous (not verified) |
204.16.59.10 |
Iowa’s Gutter Specialist LLC |
Limited Liability Company |
1390 Lark Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Dustin Halverson |
dh42312695@gmail.com |
Hampton |
IA |
United States |
Heather Halverson |
Michael Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Halverson |
dh42312695@gmail.com |
Owner |
Hampton |
IA |
United States |
Heather Marie Halverson |
Michael Alexander Halverson |
Signed |
1058 |
2022-04-19 13:19 |
Anonymous (not verified) |
50.83.154.192 |
Property Maintenance Services of Iowa LLC |
Limited Liability Company |
PO Box 166 Low Moor IA 52757 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-19 |
Frederick Stewart |
curlyfry42000@yahoo.com |
LOW MOOR |
IA |
United States |
Irene R Stewart |
Derek S Jensen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Frederick Lee Stewart |
zombiesby2012@gmail.com |
Owner |
Clinton |
IA |
United States |
Irene R Stewart |
Derek S Jensen |
Signed |
1067 |
2022-04-23 11:17 |
Anonymous (not verified) |
166.181.82.231 |
Black Squirrel Siding LLC. |
Limited Liability Partnership |
1512 north 1st ave 203s |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-23 |
Robby Bartosh |
zodzoey19@gmail.com |
Cedar Rapids |
IA |
United States |
Phoenix Bartosh |
Elijah Irish |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremiah Petsche |
Blacksquirrelsiding@gmail.com |
business partner |
coralville |
johnson |
iowa |
Phoenix Bartosh |
Elijah Irish |
Signed |
1082 |
2022-04-29 12:28 |
Anonymous (not verified) |
75.162.101.109 |
Jodi Trewet |
Proprietorship |
11920 NW 114th Ln Granger, IA 50109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-29 |
Jodi Trewet |
jtrewet@yahoo.com |
Granger |
IA |
United States |
Mark Trewet |
Tyler Trewet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jodi Trewet |
jtrewet@yahoo.com |
Same |
Granger |
Polk |
IA |
Mark Trewet |
Tyler Trewet |
Signed |
1087 |
2022-05-04 12:32 |
Anonymous (not verified) |
67.212.117.157 |
Polk's Lock Service, Inc. |
Limited Liability Partnership |
1504 College Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-04 |
Myron Piehl |
polkslockservice@gmail.com |
Cedar Falls |
IA |
United States |
Jonathon Illian |
Katrina Reyerson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Myron John Piehl |
polkslockservice@gmail.com |
owner |
Cedar Falls |
IA |
United States |
Jonathan Illian |
Katrina Clair Reyerson |
Signed |
1095 |
2022-05-12 13:20 |
Anonymous (not verified) |
173.31.29.53 |
Leaf cutter protection |
Limited Liability Company |
4146 East 23rd Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-05-12 |
Gideon Lagat |
gsaina78@gmail.com |
Des Moines |
IA |
United States |
Priscilla saina |
Cosmas nyaika |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark rond |
mbond@leaffilter.com |
Regional installation Manager |
Grimes |
Polk |
Iowa |
Priscilla saina |
Cosmas nyaika |
Signed |
1108 |
2022-05-16 16:14 |
Anonymous (not verified) |
4.4.30.34 |
David Sickels |
Proprietorship |
2221 Radcliffe Drive SW, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
David Sickels |
glsickels@gmail.com |
Cedar Rapids |
IA |
United States |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Allen Sickels |
glsickels@gmail.com |
self |
Cedar Rapids |
Linn |
Iowa |
Chad Allen Taylor |
Steven Thomas Dunn |
Signed |
1109 |
2022-05-16 19:02 |
Anonymous (not verified) |
173.20.161.18 |
Juan Manuel Alvarez |
Proprietorship |
2011 1st Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
Juan m. Alvarez |
nemen01@hotmail.com |
Perry |
IA |
IA |
Ashley lynch |
Omar Alvarez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan m. Alvarez |
nemen01@hotmail.com |
Juan |
Perry |
IA |
IA |
Ashley lynch |
Omar Alvarez |
Signed |
1114 |
2022-05-17 15:30 |
Anonymous (not verified) |
67.212.117.198 |
Busta Painting |
Limited Liability Company |
610 W 26th st #1 Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
Evan Busta |
bustapainting@gmail.com |
Cedar Falls |
IA |
United States |
Tanner Heikens |
Garrett Burrack |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evan Busta |
bustapainting@gmail.com |
Self Employeed |
Cedar Falls |
IA |
United States |
Tanner Heikens |
Garrett Burrack |
Signed |
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 |
1140 |
2022-06-02 21:20 |
Anonymous (not verified) |
167.142.38.107 |
BV Transport LLC |
Limited Liability Company |
3406 150th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-02 |
Brody Joseph Vaske |
Brody.vaske44@gmail.com |
Bancroft |
IA |
United States |
Ed Goche |
Kelly Deitering |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brody Vaske |
Brody.vaske44@gmail.com |
Self |
Bancroft |
IA |
United States |
Ed Goche |
Kelly Deitering |
Signed |
1147 |
2022-06-08 11:29 |
Anonymous (not verified) |
67.55.184.250 |
Morgan Anderson |
Proprietorship |
23379 120th Ave, Mediapolis, IA 52637 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-08 |
Morgan Duane Anderson |
morgananderson6.ma@gmail.com |
Mediapolis |
IA |
United States |
Kelly S Lanz |
Monte A Lanz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Morgan D. Anderson |
morgananderson6.ma@gmail.com |
sole proprietor |
Mediapolis |
Louisa |
Iowa |
Kelly Lanz |
Monte Lanz |
Signed |
1158 |
2022-06-17 06:34 |
Anonymous (not verified) |
97.125.255.177 |
Zach Ellis |
Proprietorship |
3013 Se Stoneridge St Grimes ia 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-17 |
Zachary Ellis |
zach2865@gmail.com |
Grimes |
IA |
United States |
Brittany Klien |
Kennedy Ellis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zachary Ellis |
zach2865@gmail.com |
Myself |
Grimes |
Polk |
Iowa |
Brittany Klien |
Kennedy Ellis |
Signed |
1174 |
2022-06-28 07:53 |
Anonymous (not verified) |
70.39.7.208 |
SG Solid Grounds |
Proprietorship |
402 3rd Ave SE State Center Iowa 50247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-27 |
Stephen Graham |
sgsolidgrounds@gmail.com |
STATE CENTER |
IA |
United States |
Stacie Graha |
Paula Atkinson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen Graham |
sgsolidgrounds@gmail.com |
Owner |
STATE CENTER |
IA |
United States |
Stacie Graham |
Paula Atkinson |
Signed |
1178 |
2022-07-05 12:02 |
Anonymous (not verified) |
172.58.122.51 |
Wright home restoration |
Limited Liability Company |
2914 South Union St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Matthew Wright |
wright.home.restoration@gmail.com |
Des Moines |
IA |
United States |
Jane wright |
Robert wright |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wright home restoration |
wright.home.restoration@gmail.com |
Myself |
Des Moines |
IA |
United States |
Jane wright |
Robert Wright |
Signed |
1182 |
2022-07-06 13:40 |
Anonymous (not verified) |
50.80.25.116 |
Beast Construction LLC |
Limited Liability Company |
1025 O Ave NW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-11 |
Gilberto Vasquez (GV Construction LLC) |
Normambazquez@gmail.com |
Iowa City |
IA |
United States |
Pedro Pinto |
Rafael Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Greg Saunders |
gsaunders@beastconstructioncr.com |
Owner |
CEDAR RAPIDS |
IA |
United States |
Laura Saunders |
Joanie Lacayo |
Signed |
1192 |
2022-07-07 21:15 |
Anonymous (not verified) |
174.242.226.74 |
Quelland Flooring |
Limited Liability Company |
P.O. Box 5, Van Meter, IA, 50261 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-07 |
Jared Tyler Quelland |
Jquelland@gmail.com |
Van Meter |
IA |
United States |
Denise Walters |
Madison Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Tyler Quelland |
Jquelland@gmail.com |
Self |
Van Meter |
IA |
United States |
Denise Walters |
Madison Mileer |
Signed |
1195 |
2022-07-08 13:24 |
Anonymous (not verified) |
174.198.67.66 |
Chapas Construction |
Limited Liability Company |
6424 Roseland Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-08 |
Polibio Raul Chapa Farez |
chapasconstructionllc@gmail.com |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Polibio Raul Chapa |
chapasconstructionllc@gmail.com |
President |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
1204 |
2022-07-14 11:59 |
Anonymous (not verified) |
107.1.252.41 |
International Drywall LLC. |
Limited Liability Company |
108 N 4th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-14 |
Victoria G Cervantes |
vic8.cervantes@gmail.com |
Marshalltown |
IA |
United States |
Rodrigo Rodriguez |
Juan Cervantes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victoria G Cervantes |
Vic8.cervantes@gmail.com |
Self |
Marshalltown |
IA |
United States |
Rodrigo Rodriguez |
Juan Cervantes |
Signed |
1209 |
2022-07-17 16:41 |
Anonymous (not verified) |
166.181.86.161 |
JustbelieveCreationsllc |
Limited Liability Company |
104 East Chestnut Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-17 |
Joshua Riera-Gomez |
josh.gomez.com@gmail.com |
Garnavillo |
IA |
United States |
Eric Jarman |
Jean brandt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Riera-Gomez |
josh.gomez.com@gmail.com |
Myself |
Garnavillo |
IA |
United States |
Eric jarman |
Jean brandt |
Signed |
1213 |
2022-07-19 14:00 |
Anonymous (not verified) |
198.14.220.143 |
VLG Build & Remodle LLC |
Limited Liability Partnership |
45547 State HWY 14 Chariton, IA 50049 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-19 |
Vladimir Golosinskiy |
VLGCONSTRUCTION@YAHOO.COM |
Chariton |
IA |
United States |
Vladimir Golosinskiy |
Vladimir Golosinskiy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LILIA GOLOSINSKIY |
VLGCONSTRUCTION@YAHOO.COM |
Wife |
CHARITON |
Iowa |
United States |
LILIA GOLOSINSKIY |
LILIA GOLOSINSKIY |
Signed |
1217 |
2022-07-21 06:51 |
Anonymous (not verified) |
209.152.88.53 |
Bullard Accounting Services, LLC |
Limited Liability Company |
4519 Scouts View Dr, Central City, IA 52214 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
Michael Bullard |
mikeandkarenbullard@gmail.com |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Bullard |
mikeandkarenbullard@gmail.com |
President of Company |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
1222 |
2022-07-21 16:01 |
Anonymous (not verified) |
66.129.208.246 |
James J Stallman |
Proprietorship |
190 BLUFF DR, Fairfax, IA 52228 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
James J Stallman |
stallmanjim@aol.com |
FAIRFAX |
IA |
United States |
James J Stallman |
James J Stallman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lundahl, Hatt, Austad Tax Services Inc |
NN@LHAtax.com |
President |
Marion |
Linn |
IA |
James J Stallman |
James J Stallman |
Signed |
1235 |
2022-08-01 17:22 |
Anonymous (not verified) |
129.222.1.151 |
KRG Gutters |
Limited Liability Company |
20376 Whiskey Rdg Ottumwa, Ia 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-01 |
Robert M Galey |
rsgaley24@yahoo.com |
Ottumwa |
IA |
United States |
Stacey Galey |
Kinnick Galey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert M Galey |
rsgaley24@gmail.com |
Self |
Ottumwa |
IA |
United States |
Stacey Galey |
Kinnick Galey |
Signed |
1237 |
2022-08-01 22:40 |
Anonymous (not verified) |
50.80.97.239 |
Andy Fiala |
Proprietorship |
1628 34th St. NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-01 |
Andy W Fiala |
fialaandy1@gmail.com |
Cedar Rapids |
IA |
United States |
John A Hasson |
Scott M Fiala |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andy W Fiala |
fialaandy1@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
John A Hasson |
Scott M Fiala |
Signed |
1241 |
2022-08-03 10:56 |
Anonymous (not verified) |
72.169.80.108 |
Landon Henriksen |
Proprietorship |
35374 GARDEN AVE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-03 |
LANDON HENRIKSEN |
HENRIKSENLK@AOL.COM |
Edgewood |
IA |
United States |
LANDON HENRIKSEN |
LANDON HENRIKSEN |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
LANDON HENRIKSEN |
HENRIKSENLK@AOL.COM |
Same |
Edgewood |
IA |
United States |
Scott Johnson |
Josh lafond |
Signed |
1247 |
2022-08-08 16:43 |
Anonymous (not verified) |
72.13.27.236 |
Williams Hardwood Flooring LLC |
Limited Liability Company |
10359 Deer Trail |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-05 |
Chad Everett Williams |
williamshardwood@aol.com |
Anamosa |
IA |
IA |
Shane Kies |
Dave Reitseger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Everett Williams |
williamshardwood@aol.com |
Owner |
Anamosa |
IA |
IA |
Shane Kies |
Dave Reitseger |
Signed |
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 |
1279 |
2022-08-22 13:17 |
Anonymous (not verified) |
50.83.54.168 |
Essex Family Construction |
Limited Liability Company |
290 Monmouth St SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-22 |
Niki Essex |
essexfamilycontruction@outlook.com |
Cedar Rapids |
IA |
IA |
Josh Lasond |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Niki Essex |
essexfamilycontruction@outlook.com |
same |
Cedar Rapids |
Iowa |
Iowa |
Josh Lasond |
Jordan Nisiewicz |
Signed |
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 |
1294 |
2022-09-04 18:09 |
Anonymous (not verified) |
38.121.112.25 |
Cabinets and Closets by Design LLC |
Limited Liability Company |
18409 250th Street, Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-04 |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
COUNCIL BLUFFS |
IA |
United States |
Jim Sietsema |
Jeff Deramcy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TIMOTHY SLOBODNIK |
cabinetsandclosetsbydesign@gmail.com |
self |
COUNCIL BLUFFS |
IA |
United States |
TIMOTHY SLOBODNIK |
TIMOTHY SLOBODNIK |
Signed |
1295 |
2022-09-05 20:39 |
Anonymous (not verified) |
173.30.59.248 |
Guide LLC |
Limited Liability Company |
1655 Ashton Place, Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-05 |
Braydon Fisher |
braydonfisher28@gmail.com |
Dubuque |
IA |
United States |
Conner Cole |
Alec Kolander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Braydon Fisher |
braydonfisher28@gmail.com |
Owner |
Dubuque |
IA |
United States |
Conner Cole |
Alex Kolander |
Signed |
1341 |
2022-10-23 14:31 |
Anonymous (not verified) |
97.127.255.147 |
Traver Home Improvement |
Limited Liability Company |
14150 110 th Ave. Davenport, IA 52804 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-24 |
Barry S Traver |
traverhomeimprovement@gmail.com |
Davenport |
IA |
United States |
Denise Baughman |
Joni Bryant |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barry S Traver |
traverhomeimprovement@gmail.com |
self |
Davenport |
IA |
United States |
Denise Baughman |
Joni Bryant |
Signed |
1347 |
2022-10-26 14:42 |
Anonymous (not verified) |
173.21.223.66 |
Mid American Roofing |
Limited Liability Company |
811 8th St Kalona IA 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-26 |
Josiah Hoyt |
midamericanroofing@gmail.com |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josiah Hoyt |
josiahhoyt@gmail.com |
Owner |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
1349 |
2022-10-28 12:37 |
Anonymous (not verified) |
173.26.153.59 |
spotlight drywall |
Proprietorship |
1001 7th st. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-01 |
paul woods |
spotlight.2008@hotmail.com |
Grundy Center |
Ia |
United States |
thuy do |
jaden do |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
thuy do |
spotlight.2008@hotmail.com |
bookeeper |
Grundy Center |
Ia |
United States |
thuy do |
jaden do |
Signed |