1863 |
2023-10-06 12:24 |
Anonymous (not verified) |
94.188.207.223 |
ADRIAN CAZARES HERNANDEZ |
Proprietorship |
409 N 16TH PL, ESTHERVILLE, IA 51334 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-06 |
ADRIAN CAZARES HERNANDEZ |
JOEL@WALKERINSURANCE.COM |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ADRIAN CAZARES HERNANDEZ |
JOEL@WALKERINSURANCEIA.COM |
SELF |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1873 |
2023-10-20 09:25 |
Anonymous (not verified) |
94.188.207.228 |
GC Hauling LLC |
Limited Liability Company |
310 North 18th Street, Indianola, IA, 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-20 |
Garrett Joseph Claerhout |
gjclaerhout@hotmail.com |
INDIANOLA |
IA |
IA |
Kirsten Claerhout |
Jay Claerhout |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Garrett Joseph Claerhout |
gjclaerhout@hotmail.com |
Same Person |
INDIANOLA |
IA |
IA |
Kirsten Claerhout |
Jay Claerhout |
Signed |
1874 |
2023-10-22 11:54 |
Anonymous (not verified) |
94.188.205.166 |
Midwest UAV LLC |
Limited Liability Company |
1400 15th St SE Bondurant Iowa 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-22 |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Owner |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
1877 |
2023-10-23 15:49 |
Anonymous (not verified) |
94.188.207.228 |
Craig Michael Wilson |
Proprietorship |
24538 118th Street, Columbus Junction, IA 52738 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-16 |
Craig Michael Wilson |
tripod109@hotmail.com |
Columbus Junction |
Louisa |
IA |
Brenda Wilson |
Ruger Dean |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Craig Michael Wilson |
tripod109@hotmail.com |
Self |
Columbus Junction |
Louisa |
IA |
Brenda Wilson |
Ruger Dean |
Signed |
1882 |
2023-10-27 10:40 |
Anonymous (not verified) |
94.188.205.166 |
Ron's SIding and Construction |
Proprietorship |
6097 26th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2025-02-02 |
Ron Heggebo |
heggebojessica@yahoo.com |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronnie Heggebo |
heggebojessica@yahoo.com |
self |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
1883 |
2023-10-27 10:49 |
Anonymous (not verified) |
94.188.207.228 |
Ron's SIding and Construction |
Proprietorship |
6097 26th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-27 |
Ron Heggebo |
heggebojessica@yahoo.com |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Heggebo |
heggebojessica@yahoo.com |
Self |
Vinton |
Benton |
IA |
Jessica Heggebo |
Jessica Heggebo |
Signed |
1884 |
2023-10-27 18:32 |
Anonymous (not verified) |
94.188.205.177 |
J&M dry wall |
Proprietorship |
948 Kern St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-27 |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Waterloo |
Black hawk |
IA |
Luis flores |
Luis flores |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Self |
Waterloo |
Black hawk |
IA |
Luis Flores |
Luis flores |
Signed |
1889 |
2023-11-01 06:44 |
Anonymous (not verified) |
94.188.207.226 |
Williams Hardwood Flooring LLC |
Limited Liability Company |
P.O. Box 22 Marion, Ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-01 |
Chad Everett William |
williamshardwoodflooringllc@gmail.com |
Anamosa |
Jones |
IA |
Tara Williams |
Sarah Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad E Williams |
williamsharfwoodflooringllc@gmail.com |
Me |
Anamosa |
Jones |
IA |
Tara Williams |
Sarah Williams |
Signed |
1890 |
2023-11-01 19:22 |
Anonymous (not verified) |
94.188.207.228 |
JACK SCHADE |
Proprietorship |
911 Broad St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-01 |
jack allan schade |
jackschade@yahoo.com |
Plymouth |
IA |
IA |
jack allan schade |
jack allan schade |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jack allan schade |
jackschade@yahoo.com |
self |
Plymouth |
IA |
IA |
jack allan schade |
jack allan schade |
Signed |
1891 |
2023-11-02 06:24 |
Anonymous (not verified) |
94.188.207.225 |
DOC Services |
Proprietorship |
3313 , E 7th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-01 |
Quentin Ferguson |
1quensy@gmail.com |
Des Moines |
Polk |
IA |
Dione Fergsuon |
Quensy Ferguson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Quentin Ferguson |
1quensy@gmail.com |
Self |
Des Moines |
Polk |
Ia |
Dione Ferguson |
Quensy Ferguson |
Signed |
1892 |
2023-11-02 12:24 |
Anonymous (not verified) |
94.188.205.169 |
TREJO'S CONSTRUCTION LLC |
Limited Liability Company |
1113 L AVE, MILFORD, IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-02 |
CHARVEL TREJO |
levrach@yahoo.com |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CHARVEL TREJO |
levrach@yahoo.com |
SELF |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1893 |
2023-11-02 14:39 |
Anonymous (not verified) |
94.188.205.177 |
Dagoberto Nuñez |
Proprietorship |
Iowa city |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-02 |
Dagoberto Nuñez |
nunezdagoberto730@gmail.com |
833 basswood ln iowa city |
Johnson |
IA |
Darwin salgado |
Ramon nuñez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dagoberto Nuñez |
nunezdagoberto730@gmail.com |
Yo mismo |
Iowa city |
Johnson |
IA |
Darwin Salgado |
Ramon nuñez |
Signed |
1894 |
2023-11-03 10:02 |
Anonymous (not verified) |
94.188.205.167 |
ASHLEY QUAIL DBA: RUSTIC ROOTS SALON |
Proprietorship |
33596 SCHANY DR, RUTHVEN, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-03 |
ASHLEY QUAIL |
ashley-mazzanti@hotmail.com |
RUTHVEN |
PALO ALTO |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ASHLEY QUAIL |
ashley-mazzanti@hotmail.com |
SELF |
RUTHVEN |
PALO ALTO |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1895 |
2023-11-03 12:21 |
Anonymous (not verified) |
94.188.207.227 |
Oxbo LLC |
Limited Liability Company |
2528 Evergreen Ave. Red Oak, IA 51566 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-03 |
Mettra Sperling |
sperlingrose66@gmail.com |
Red Oak |
Montgomery |
IA |
Chantal Sperling |
Derek Penry |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mettra Sperling |
sperlingrose66@gmail.com |
Self |
Red Oak |
Montgomery |
IA |
Chantal Sperling |
Derek Penry |
Signed |
1897 |
2023-11-06 09:12 |
Anonymous (not verified) |
94.188.205.177 |
Matthew Jones |
Limited Liability Company |
124 NE 49th 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. |
2023-11-06 |
Matthew Jones |
mjj4242@gmail.com |
Ankeny |
Polk |
IA |
Duan Willform |
AJ Giebelstein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Jones |
mjj4242@gmail.com |
Self |
Ankeny |
Polk |
IA |
AJ Giebelstein |
Duan Willform |
Signed |
1898 |
2023-11-09 09:56 |
Anonymous (not verified) |
94.188.207.227 |
RC Restoration LLC |
Limited Liability Company |
991 June Drive, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-09 |
Luke Hoffmann |
luke@rentcube.com |
Dubuque |
Dubuque |
Iowa |
Randi Taylor |
Carla Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Hoffman |
luke@rentcube.com |
Owner |
Dubuque |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
1907 |
2023-11-15 09:45 |
Anonymous (not verified) |
94.188.205.168 |
Dan Taylor |
Proprietorship |
1422 State ST. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-15 |
Daniel Taylor |
mailrunner1958@gmail.com |
Mason City |
Cerro Gordo |
IA |
Bob Smith |
Dave Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Taylor |
mailrunner1958@gmail.com |
employee |
Mason City |
Cerro Gordo |
IA |
Bob Smith |
Dave Clark |
Signed |
1910 |
2023-11-15 13:06 |
Anonymous (not verified) |
94.188.207.228 |
RODRIGUEZ ENTERPRISES III INC |
Limited Liability Company |
905 W US HIGHWAY 30 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. |
2023-11-14 |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
CARROLL |
CARROLL |
IOWA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
OWNER |
CARROLL |
CARROLL |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
1912 |
2023-11-16 08:40 |
Anonymous (not verified) |
94.188.205.175 |
JC LANDSCAPING & LAWN CARE |
Proprietorship |
4940 E. SHERIDAN AVE DES MOINES, IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-16 |
CLAUDIA TORO PINEDA |
CLAUDIAMEP@HOTMAIL.COM |
DES MOINES |
POLK |
IA |
BRENDA REEDY |
ADAM SMITH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CLAUDIA TORO PINEDA |
CLAUDIAMEP@HOTMAIL.COM |
SELF |
DES MOINES |
POLK |
IA |
BRENDA REEDY |
ADAM SMITH |
Signed |
1913 |
2023-11-20 13:48 |
Anonymous (not verified) |
94.188.205.167 |
KWF SALES INC |
Proprietorship |
216 WINDFLOWER LANE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-20 |
KRISTI A WOODLEY-FLANSBURG |
Kwflansburg@gmail.com |
SOLON |
Iowa |
Iowa |
ZACH GRANT |
TOM SIMPSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KRISTI A WOODLEY-FLANSBURG |
Kwflansburg@gmail.com |
SELF |
SOLON |
IA |
IA |
ZACH GRANT |
TOM SIMPSON |
Signed |
1916 |
2023-11-21 12:31 |
Anonymous (not verified) |
94.188.205.174 |
DC Painting |
Proprietorship |
205 Astor St, Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-03 |
Damion Clement |
gcort06@gmail.com |
Des Moines |
Polk |
IA |
Brandi Haight |
Dennis Clement |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Damion Clement |
gcort06@gmail.com |
Owner |
205 Astor Street |
Polk |
IA |
Brandi Haight |
Dennis Clement |
Signed |
1919 |
2023-11-21 14:11 |
Anonymous (not verified) |
94.188.207.227 |
Refined Construction |
Limited Liability Company |
4148 Mattern ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-21 |
Dustin Martin |
dudtin.martin106@gmail.com |
Des Moines |
Polk |
IA |
Kelsey Baldinelli |
Brandi Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Martin |
dustin.martin106@gmail.com |
Sole officer |
Des Moines |
Polk |
IA |
Kelsey Baldinelli |
Brandi Martin |
Signed |
1920 |
2023-11-22 08:40 |
Anonymous (not verified) |
94.188.205.166 |
Demolition Services of Iowa, llc |
Limited Liability Company |
221 North Grant Ave., Elkhart, IA 50073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-22 |
William Albert Halterman |
DemolitionServicesIA@gmail.com |
ELKHART |
IA |
United States |
Ashley Whitehill |
Zach Whitehill |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Albert Halterman |
DemolitionServicesIA@gmail.com |
self |
Elkhart |
Polk |
IA |
Ashley Nicole Lee Whitehill |
Zachery Allen Whitehill |
Signed |
1929 |
2023-11-30 10:46 |
Anonymous (not verified) |
94.188.207.225 |
White Masonry, Inc. |
Proprietorship |
15141 Bluff Trl., Carlisle, IA 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-30 |
Jeff White |
whitemasonry1979@hotmail.com |
Carlisle |
IA |
IA |
Cathleen Marie White |
Sam Jeffrey White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeffrey Dean White |
WHITEMASONRY1979@HOTMAIL.COM |
Self |
CARLISLE |
ia |
ia |
Cathleen Marie White |
Sam Jeffrey White |
Signed |
1931 |
2023-12-01 18:01 |
Anonymous (not verified) |
94.188.207.225 |
Jay Wang |
Limited Liability Company |
16672 Verona Hills Dr, Clive IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-01 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
US |
IA |
WenHui chen |
Yingna Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
Jaywang@wasabidsm.com |
Self |
Clive |
US |
IA |
WenHui Chen |
Yingna Zheng |
Signed |
1935 |
2023-12-02 18:34 |
Anonymous (not verified) |
94.188.207.229 |
Wasabi Johnston LLC |
Limited Liability Company |
8184 Birchwood Ct, Johnston IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-02 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
Dallas |
IA |
Engjin zheng |
yingna Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
jaywang@wasabidsm.com |
self |
Clive |
Dallas |
IA |
Wenhui Cheng |
Enjing Zheng |
Signed |
1939 |
2023-12-05 14:32 |
Anonymous (not verified) |
94.188.207.229 |
PJ Trucking Unlimited LLC |
Limited Liability Company |
2617 380th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-05 |
Peggy Jensen |
pegandhalj@gmail.com |
Farragut |
US |
IA |
Darlene |
Julie Ann Marshsll |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peggy Jensen |
pegandhalj@gmail.com |
self |
Farragut |
US |
IA |
Darlene Carpenter |
Julie Marshall |
Signed |
1941 |
2023-12-06 11:52 |
Anonymous (not verified) |
94.188.205.167 |
GUEVARA CONCRETE LLC |
Limited Liability Company |
26 WESTVIEW DR APT 5 MILFORD, IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IA |
TAMI SUE KLEIN |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IA |
TAMI SUE KLEIN |
JENNIFER JANET YOUNGWIRTH |
Signed |
1947 |
2023-12-07 16:01 |
Anonymous (not verified) |
94.188.205.176 |
Reinier Construction LLC |
Limited Liability Company |
1406 Linden Lane |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-07 |
David J Reinier |
reinierconst@aol.com |
Des Moines |
Polk |
IA |
PEGGY A ROHDE |
Douglas E Rohde |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PEGGY A ROHDE |
dnprohde@msn.com |
Bookkeeper |
Polk City |
Polk |
IA |
Douglas E Rohde |
Stacie L Miller |
Signed |
1953 |
2023-12-12 15:38 |
Anonymous (not verified) |
94.188.207.226 |
Ryan Gideon |
Proprietorship |
9320 Elmcrest Dr Norwalk, Ia 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-12 |
Ryan Gideon |
rgid8403@gmail.com |
Norwalk |
Warren |
IA |
Jim Lane |
Jim Lane |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Gideon |
rgid8403@gmail.com |
Owner |
Norwalk |
Warren |
IA |
jim Lane |
Jim Lane |
Signed |
1954 |
2023-12-13 13:51 |
Anonymous (not verified) |
94.188.207.227 |
Beeson Trucking LLC |
Limited Liability Company |
219 Tilden St Kingsley IA 51028 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-13 |
Jeremy Beeson |
jeremy4k78@yahoo.com |
Kingsley |
Plymouth |
IA |
Katherine Weaver |
Darla Robley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremy Beeson |
jeremy4k78@yahoo.com |
Self |
Kingsley |
Plymouth |
IA |
Katherine Weaver |
Darla Robley |
Signed |
1960 |
2023-12-16 11:58 |
Anonymous (not verified) |
94.188.207.227 |
Landeros Framing |
Proprietorship |
2418 E 37th Ct |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-16 |
Francisco Javier Landeros Garcia |
garcialanderosfranciscojavier@gmail.com |
Des Moines |
IA |
IA |
Mirna Ruby |
Jose Gaytan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Francisco Javier Landeros Garcia |
garcialanderosfranciscojavier@gmail.com |
owner |
Des Moines |
IA |
IA |
Mirna Ruby |
Jose Gaytan |
Signed |
1964 |
2023-12-22 10:19 |
Anonymous (not verified) |
94.188.207.224 |
Dale Pahl |
Proprietorship |
711 N. 1St. B105 Eldridge IA 52748 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-21 |
Dale Pahl |
Pada7910@gmail.com |
Eldridge |
Scott |
Iowa |
Samantha weston |
Rick mayerhofer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dale |
Pada7910@gmail.com |
Self |
Eldridge |
Scott |
IA |
Samantha weston |
Rick Mayerhofer |
Signed |
1965 |
2023-12-22 10:23 |
Anonymous (not verified) |
94.188.207.229 |
Shawn Cooney |
Proprietorship |
4425 Ne 34th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-22 |
Shawn Nelson Cooney |
shawncooney59@gmail.com |
Des Moines |
polk |
IA |
Marie Cooney |
Shawntel Cooney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Cooney |
shawncooney59@gmail.com |
Myself |
Des Moines |
polk |
IA |
Marie Cooney |
Shawntel Cooney |
Signed |
1970 |
2023-12-29 10:01 |
Anonymous (not verified) |
94.188.205.168 |
Beatrice Banura |
Proprietorship |
14511 Bentwood Dr, Urbandale IA 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-29 |
Beatrice Banura |
banurabeatrice4@gmail.com |
Urbandale |
Dallas |
IA |
Priscilla Saina |
Gideon Saina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beatrice Banura |
banurabeatrice4@gmail.com |
Self employed |
Urbandale |
IA |
IA |
Priscilla Saina |
Gideon Saina |
Signed |
1972 |
2024-01-02 14:19 |
Anonymous (not verified) |
94.188.205.174 |
Parker Trucking LLC |
Limited Liability Company |
1507 Greene Street Adel, IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-02 |
Michael Craig Parker |
mcparker31@msn.com |
Adel |
Dallas |
Iowa |
Jessie Rynearson |
Melisha Rynearson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Parker |
mcparker31@msn.com |
Owner/Memeber |
Adel |
Dallas |
IA |
Jessie Rynearson |
Melishia Rynearson |
Signed |
1975 |
2024-01-04 15:42 |
Anonymous (not verified) |
94.188.207.229 |
Blake S. Judisch Masonry LLC |
Limited Liability Company |
510 South Fulton St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-04 |
Blake Judisch |
blakejudisch@gmail.com |
Shell rock |
Butler |
IA |
Kali Judisch |
Terri Thomsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Judisch |
blalejudisch@gmail.com |
Owner |
Shell rock |
Butler |
IA |
Kali Judisch |
Terri Thomsen |
Signed |
1976 |
2024-01-04 15:48 |
Anonymous (not verified) |
94.188.207.224 |
Brawdy Services |
Proprietorship |
7029 Prairie Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-01 |
Victor Brawdy |
heather.l.brawdy@gmail.com |
Urbandale |
Polk |
IA |
Summer Munoz |
Jennifer Wolters |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victor Brawdy |
vb69ia@gmail.com |
Self |
Urbandale |
Polk |
IA |
Summer Munox |
Jennifer Wolters |
Signed |
1977 |
2024-01-05 13:25 |
Anonymous (not verified) |
94.188.207.228 |
BOYOK BUILDS, LLC |
Limited Liability Company |
25395 140TH ST, SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-04 |
VITALE BOYOK |
BOYOK68@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
VITALE BOYOK |
BOYOK68@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1978 |
2024-01-08 13:28 |
Anonymous (not verified) |
94.188.205.167 |
TYREL GIBSON |
Proprietorship |
2004 CHICAGO AVE SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-08 |
TYREL GIBSON |
TY11TEKFALL@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
TYREL GIBSON |
TY11TEKFALL@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1982 |
2024-01-11 12:29 |
Anonymous (not verified) |
94.188.205.166 |
Grace Justine |
Proprietorship |
405 Northview Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-11 |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
own |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
1983 |
2024-01-11 13:02 |
Anonymous (not verified) |
94.188.205.168 |
r&k propety solutions |
Proprietorship |
po box 53 cedar rapids iowa 52406 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-11 |
roy rohwedder |
rohwedder.roy@yahoo.com |
Cedar Rapids |
linn |
ia |
Brian Ashlock |
tim vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Center Point |
Benton |
ia |
Tim Vaske |
Roy Rohwedder |
Signed |
1984 |
2024-01-15 17:33 |
Anonymous (not verified) |
94.188.207.227 |
Jay Wang |
Limited Liability Company |
8481 Birchwood Ct, Johnston |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-15 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
US |
IA |
Yingna Zheng |
Qiaoqiao Li |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
jaywang@wasabidsm.com |
Self |
Clive |
US |
IA |
Yingna Zheng |
Qiaoqiao Li |
Signed |
1988 |
2024-01-16 15:22 |
Anonymous (not verified) |
94.188.205.176 |
Harmons Home Services LLC |
Limited Liability Company |
605 w Cedar st, Cherokee, IA, 51012 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-16 |
Shawn Michael Harmon |
harmonsheatingandair@gmail.com |
Cherokee |
Ia |
United States |
Shawn Harmon |
Sara Harmon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shawn Michael Harmon |
Harmonsheatingandair@gmail.com |
Self |
Cherokee |
Cherokee |
IA |
Shawn Harmon |
Sara Harmon |
Signed |
1989 |
2024-01-16 17:13 |
Anonymous (not verified) |
94.188.205.168 |
Xcel Electric LLC |
Limited Liability Company |
1142 Columbus Dr Waterloo Ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-16 |
Haris Mumic |
h.mumic@hotmail.com |
Waterloo |
Black Hawk |
IA |
Minea Skrgic-Mumic |
Elvis Mumic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Haris Mumic |
h.mumic@hotmail.com |
Owner/Employer |
waterloo |
Black Hawk |
IA |
Minea Skrgic-Mumic |
Elvis Mumic |
Signed |
1997 |
2024-01-25 11:09 |
Anonymous (not verified) |
94.188.207.225 |
Abstract Associates of Iowa Inc. |
Proprietorship |
822 Central Ave Ste 304 Fort Dodge, IA 50501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-21 |
Ted Hugghins |
tjhugghins@abstractassociatesofiowa.com |
Fort Dodge |
Webster |
Iowa |
Mariah Ayala |
Bennett O'Connor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ted Hugghins |
tjhugghins@abstractassociatesofiowa.com |
President |
Fort Dodge |
Webster |
IA |
Mariah Ayala |
Bennett O'Connor |
Signed |
2000 |
2024-01-26 10:05 |
Anonymous (not verified) |
94.188.205.177 |
Nick Myers Construction |
Proprietorship |
4736 Candlewick Drive, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-26 |
Nicholas Myers |
myersnicholasj@gmail.com |
Norwalk |
Warren |
Iowa |
John Myers |
Brenda Myers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Myers |
nickmyersconstruction@gmail.com |
Owner |
Norwalk |
IA |
IA |
John Myers |
Brenda Myers |
Signed |
2002 |
2024-01-26 17:00 |
Anonymous (not verified) |
94.188.207.228 |
Legacy Group Consulting |
Limited Liability Company |
3721 Coppermill Rd NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-26 |
John A Scott |
legacygrpconsulting@gmail.com |
Cedar Rapids |
Linn |
IA |
Barbara Scott |
Robert Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John A Scott |
legacygrpconsulting@gmail.com |
Owner |
Cedar Rapids |
Linn |
IA |
Barbara Scott |
Robert Moore |
Signed |
2003 |
2024-01-28 12:38 |
Anonymous (not verified) |
94.188.205.169 |
Wasabi Urbandale LLC |
Limited Liability Company |
2301 Rocklyn Dr, Urbandale IA 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-01 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
Dallas |
IA |
Ajdin Nadarich |
Jeremy Boysen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
jaywang@wasabidsm.com |
Self |
Clive |
Dallas |
IA |
Lisa Lee |
Yingna Zheng |
Signed |
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 |
2034 |
2024-02-07 11:58 |
Anonymous (not verified) |
94.188.207.230 |
Bryce Abbott |
Proprietorship |
114 West Linn Street, Lone Tree, IA 52755 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-31 |
Bryce David Abbott |
bryceabbott86@gmail.com |
Lone Tree |
Johnson |
United States |
Dixie Abbott |
Andy Abbott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryce Abbott |
bryceabbott86@gmail.com |
Self |
Lonetree |
Johnson |
IA |
Dixie Abbott |
Andy Abbott |
Signed |
2038 |
2024-02-08 07:44 |
Anonymous (not verified) |
94.188.205.167 |
Travis Toney |
Limited Liability Company |
932 w12th street south newton ia 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Travis Duane Toney |
travistoney1984@gmail.com |
Newton |
United States |
IA |
Rick lee Toney |
Brenda Ann Toney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Phil glazer |
kg_Info@capitallandscaping.com |
Contractor |
Des Moines |
United States |
IA |
Rick lee Toney |
Brenda Ann Toney |
Signed |
2042 |
2024-02-12 13:07 |
Anonymous (not verified) |
94.188.205.175 |
Evelyn R Ventura Terrazas |
Proprietorship |
524 Terrence |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-12 |
Evelyn R Ventura Terrazas |
evelynterrazas@gmail.com |
Storm Lake |
Buena vista |
IA |
Juan García Oropeza |
Karen Rodríguez Pantoja |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evelyn R Ventura Terrazas |
evelynterrazas@gmail.com |
Proprietorship |
Storm Lake |
Buena vista |
IA |
Juan Garcia Oropeza |
Karen Rodríguez Pantoja |
Signed |
2048 |
2024-02-16 07:42 |
Anonymous (not verified) |
94.188.207.224 |
Alexandra Machedon LLC |
Proprietorship |
319 N Western Street Stuart, IA 50250 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-16 |
Alexandra Machedon |
ali@alimachedon.com |
Stuart |
USA |
Iowa |
Jessica Cash |
Vicki Collins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alexandra Machedon |
ali@alimachedon.com |
Self |
Stuart |
US |
IA |
Jessi Cash |
Vicki Collins |
Signed |
2060 |
2024-02-28 09:36 |
Anonymous (not verified) |
94.188.207.228 |
BRANDON LEHNER |
Proprietorship |
308 SANFORD STREET ARCHER IA 51231 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-28 |
BRANDON LEHNER |
BLEHNER302@GMAIL.COM |
ARCHER |
OBRIEN |
IA |
TAMI KLEIN |
JOSEPH LORING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BRANDON LEHNER |
BLEHNER302@GMAIL.COM |
SELF |
ARCHER |
OBRIEN |
IA |
TAMI KLEIN |
JOSEPH LORING |
Signed |
2063 |
2024-02-29 10:12 |
Anonymous (not verified) |
94.188.205.177 |
Geral Lee Pattison |
Proprietorship |
22127 Hwy 52 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-29 |
Geral Lee Pattison |
pattisonglee@gmail.com |
GARNAVILLO |
IA |
IA |
Lee Zapf |
Andrew Corllet |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Geral Lee Pattison |
pattisonglee@gmail.com |
Self |
GARNAVILLO |
IA |
IA |
Lee Zapf |
Andrew Corllet |
Signed |
2064 |
2024-02-29 11:53 |
Anonymous (not verified) |
94.188.207.227 |
Quality Masonry LLC |
Limited Liability Company |
4121 14th st des moines ia 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-29 |
Wilian Nunez |
williamnunez77@gmail.com |
Des Moines |
IOWA |
United States |
Drake Rapaich |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wilian Nunez |
Williamnunez77@gmail.com |
Self |
Des Moines |
Polk |
IA |
Drake Rapaich |
Nathan Miller |
Signed |
2066 |
2024-02-29 15:27 |
Anonymous (not verified) |
94.188.207.230 |
Julian Abey |
Proprietorship |
4405 NW Abilene Road, Ankeny IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-29 |
Julian Abey |
Jabeyhpro@gmail.com |
Ankeny |
Polk |
IA |
Eric Ndifon |
Peter Gara |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Julian Abey |
Jabeyhpro@gmail.com |
Self |
Ankeny |
IA |
IA |
Eric Ndifon |
Peter Gara |
Signed |
2067 |
2024-02-29 16:58 |
Anonymous (not verified) |
94.188.205.166 |
James Baker |
Limited Liability Company |
1510 E 1st Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-01 |
James Baker |
jaykeribaker@yahoo.com |
Indianola |
Warren |
IA |
Keri Baker |
Brenan Baker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Baker |
jaykeribaker@yahoo.com |
Self |
Indianola |
Warren |
IA |
Keri Baker |
Brenan Baker |
Signed |
2070 |
2024-03-01 10:21 |
Anonymous (not verified) |
94.188.205.167 |
J&W siding LLC |
Limited Liability Company |
302 West Lincoln street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-01 |
william t Belz |
5.4tritonf150@gmail.com |
Walcott |
IA |
IA |
william t Belz |
william t Belz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
william t Belz |
5.4tritonf150@gmail.com |
owner |
Walcott |
IA |
IA |
william t Belz |
william t Belz |
Signed |
2071 |
2024-03-01 11:08 |
Anonymous (not verified) |
94.188.207.229 |
Level92 Screen Printing LLC |
Limited Liability Company |
2500 W 2nd Ave Ste 10, Indianola, IA 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-01 |
Alison Vice |
orders@level92.com |
Indianola |
Warren |
IA |
Jake Vice |
Grant Darrah |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alison Vice |
orders@level92.com |
Partner |
Indianola |
Warren |
IA |
Jake Vice |
Grant Darrah |
Signed |
2072 |
2024-03-01 11:27 |
Anonymous (not verified) |
94.188.207.226 |
SoldFast Real Estate L.L.C. |
Limited Liability Company |
5525 Meredith Drive Des Moines, Iowa 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-02 |
Darlyn Fructuoso |
thejjscleaningllc@gmail.com |
Des Moines |
Polk |
IA |
Beatriz Musselman |
Darlyn Fructuoso |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Wilkinson |
cody@soldfast.com |
Contractor |
Des Moine |
Polk |
IA |
Beatriz Musselman |
Darlyn Fructuoso |
Signed |
2073 |
2024-03-04 15:51 |
Anonymous (not verified) |
94.188.207.227 |
JACOB HANSON |
Proprietorship |
415 N 18TH ST ESTHERVILLE, IA 51334 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-04 |
JACOB HANSON |
HANSONONEBOY@GMAIL.COM |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JACOB HANSON |
HANSONONEBOY@GMAIL.COM |
SELF |
ESTHERVILLE |
EMMET |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
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 |
2083 |
2024-03-08 14:41 |
Anonymous (not verified) |
94.188.205.169 |
Michael Dwayne Wahl Jr DBA Dents Etc |
Proprietorship |
3458 Highway 65/69, Carlisle, Iowa 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-08 |
Michael Dwayne Wahl Jr |
darrin@fisherbodypaint.com |
Carlisle |
Polk |
Iowa |
Darrin Morrison |
Anthony Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Schreck |
mark.schreck@insurancestationinc.com |
Agent |
Altoona |
IA |
IA |
Darrin Morrison |
Anthony Garcia |
Signed |
2084 |
2024-03-08 15:18 |
Anonymous (not verified) |
94.188.207.230 |
Heidi Vincent |
Proprietorship |
2213 SW White Birch Dr, Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-18 |
Heidi Vincent |
jared.vincent@insurancestationinc.com |
Ankeny |
Polk |
Iowa |
Jared Vincent |
Colton Horak |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Schreck |
mark.schreck@insurancestationinc.com |
Agent |
Altoona |
IA |
IA |
Jared Vincent |
Colton Horack |
Signed |
2085 |
2024-03-08 15:22 |
Anonymous (not verified) |
94.188.207.227 |
Laura Cook |
Proprietorship |
2213 SW White Birch Dr, Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-18 |
Laura Cook |
jared.vincent@insurancestationinc.com |
Ankeny |
Polk |
Iowa |
Jared Vincent |
Colton Horak |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Schreck |
mark.schreck@insurancestationinc.com |
Agent |
Altoona |
IA |
IA |
Jared Vincent |
Colton Horack |
Signed |
2088 |
2024-03-12 10:44 |
Anonymous (not verified) |
94.188.207.226 |
Elmer Henry Vicente Lopez |
Proprietorship |
1602 Court St Apt 2 Sioux City, IA 51105 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Elmer Henry Vicente Lopez |
vicenteelmer33@gmail.com |
Sioux City |
Woodbury |
Iowa |
Adrian Dominguez |
Ronald Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Halverson |
ron@sppinsurance.com |
independent contractor |
Cherokee |
Cherokee |
IA |
Elmer Henry Vicente Lopez |
Ronald Halverson |
Signed |
2090 |
2024-03-12 14:16 |
Anonymous (not verified) |
94.188.205.169 |
Oscar Sosa |
Proprietorship |
110 E Cherry St Cherokee, IA 51012 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Oscar Sosa |
oscarsosa@live.com |
Cherokee |
Cherokee |
Iowa |
Adrian Dominguez |
Ronald Halverson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron Halverson |
ron@sppinsurance.com |
independent contractor |
Cherokee |
Cherokee |
IA |
Oscar Sosa |
Ronald Halverson |
Signed |
2092 |
2024-03-13 12:55 |
Anonymous (not verified) |
94.188.205.175 |
Banker's Lock and Safe |
Proprietorship |
1914 Porter Ave Des Moines Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-13 |
Jeff Losee |
bankerslockandsafe@yahoo.com |
Des Moines |
Polk |
IA |
Jennifer D Losee |
Kendra D Losee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeff Losee |
bankerslockandsafe@yahoo.com |
Owner |
Des Moines Iowa |
Polk |
IA |
Jennifer D Losee |
Kendra D Losee |
Signed |
2100 |
2024-03-17 12:36 |
Anonymous (not verified) |
94.188.205.167 |
Donovan Electric LLC |
Limited Liability Company |
857 Tipperary rd Iowa City iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-17 |
Bill Donovan |
bill@donovanelectricllc.com |
Iowa City |
Johnson |
IA |
Bo Nock |
Stephanie Ineichen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Donovan |
blaked@donovanelectricllc.com |
Partner |
Iowa City |
Johnson |
IA |
Bo Nock |
Stephanie Ineichen |
Signed |
2114 |
2024-03-25 18:18 |
Anonymous (not verified) |
94.188.207.227 |
Lisa V Blessington |
Proprietorship |
411 S 10th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-25 |
Lisa Varie Blessington |
lblessington@yahoo.com |
Sac City |
Sac |
IA |
Jean Rexroat |
Jennifer Tovar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisa Varie Blessington |
lblessington@yahoo.com |
Same |
Sac City |
Sac |
IA |
Jean Rexroat |
Jennifer Tovar |
Signed |
2115 |
2024-03-26 14:53 |
Anonymous (not verified) |
94.188.207.223 |
DICKINSON COUNTY CLEANING AND MAINTENANCE, LLC |
Limited Liability Company |
414 19TH ST PO BOX 182 SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-26 |
LISA ARROWOOD |
lisa.arrowood1126@gmail.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LISA ARROWOOD |
lisa.arrowood1126@gmail.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
2144 |
2024-04-10 14:23 |
Anonymous (not verified) |
94.188.205.176 |
Heaven Sent PC LLC |
Limited Liability Company |
604 Allamakee St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-10 |
Justin PIggott |
heavensentpetcremation@gmail.com |
Waukon |
Allamakaee |
IA |
Jane M Regan |
Nancy Bechtel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Piggott |
heavensentpetcremation@gmail.com |
LLC Member |
Waukon |
Allamakee |
IA |
Jane M Regan |
Nancy Bechtel |
Signed |
2152 |
2024-04-15 17:23 |
Anonymous (not verified) |
94.188.207.230 |
ServiceMaster by Harris |
Proprietorship |
432 Locust Street Waterloo, IA 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-15 |
Joel Harris |
joel.harris@forbin.net |
Waterloo |
IA |
IA |
None |
None |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Harris |
joel.harris@forbin.net |
Owner |
Waterloo |
IA |
IA |
None |
None |
Signed |
2157 |
2024-04-17 11:16 |
Anonymous (not verified) |
94.188.205.168 |
LAKESIDE DETAILING LLC |
Limited Liability Company |
249 EMERALD MEADOWS DR, ARNOLDS PARK, IA 51331 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-17 |
DYLAN MCHUGH |
19DMCHUGH@GMAIL.COM |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DYLAN MCHUGH |
19DMCHUGH@GMAIL.COM |
SELF |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
2170 |
2024-04-22 10:11 |
Anonymous (not verified) |
94.188.207.224 |
Joy Ride Transport |
Limited Liability Company |
3105 SE Miehe Drive, Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Ted Cochran |
ted@ridejoyride.com |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ted Cochran |
ted@ridejoyride.com |
Self |
Clive |
Dallas |
IA |
Lindsey Pace |
Carissa Gehrking |
Signed |
2181 |
2024-04-25 15:41 |
Anonymous (not verified) |
94.188.205.168 |
Ev's Ice Cream LLC |
Limited Liability Company |
2205 1/2 S Center St, Marshalltown, IA 50158-5960 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-25 |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Self |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
2182 |
2024-04-25 19:37 |
Anonymous (not verified) |
94.188.205.174 |
Curtis Bunnell sub contractor |
Proprietorship |
907 s main st sigourney IA 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-23 |
CURTIS BUNNELL |
curt3551.cb@gmail.com |
Sigourney |
Keokuk |
IA |
Latisha Bunnell |
Wendy Yeo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Curtis bunnell |
curt3551.cb@gmail.com |
Same person |
Sigourney |
Keokuk |
IA |
Latisha bunnell |
Wendy Yeo |
Signed |
2192 |
2024-04-29 13:15 |
Anonymous (not verified) |
94.188.205.166 |
ElmStreet Apothecary |
Limited Liability Company |
320 W Kimberly Road #227 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Erica McGee |
esalsbury07@gmail.com |
Bettendorf |
Scott |
Ia |
Jennifer West |
Julie Francis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erica McGee |
esalsbury07@gmail.com |
Self |
Bettendorf |
Scott |
Ia |
Jennifer West |
Julie Francis |
Signed |
2204 |
2024-05-06 18:56 |
Anonymous (not verified) |
94.188.205.168 |
Jim saukko |
Proprietorship |
13232 nw 30 th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-05 |
Jim Saukko |
saukkogt500@gmail.com |
Polk city |
IA |
United States |
Dawn brown |
Kirk moser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jim Saukko |
saukkogt500@gmail.com |
Self |
Polk city |
IA |
IA |
Dawn brown |
Kirk moser |
Signed |
2206 |
2024-05-07 09:10 |
Anonymous (not verified) |
94.188.205.166 |
Stephanie Farmer |
Proprietorship |
600 6th Ave, Marion, IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-07 |
Stephanie Farmer |
farmer.stephanie22@gmail.com |
Marion |
Linn |
IA |
Chris Farmer |
Deb Hartz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Farmer |
farmer.stephanie22@gmail.com |
Self |
Marion |
Linn |
IA |
Chris Farmer |
Deb Hartz |
Signed |
2209 |
2024-05-07 15:03 |
Anonymous (not verified) |
94.188.207.225 |
THE FURNITURE GIRL LLC |
Limited Liability Company |
19257 CONIFER LN COUNCIL BLUFFS, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-07 |
PATTI WIGGINS |
pwiggins@npdodge.com |
VILLISCA |
MONTGOMERY |
IA |
NATHAN HULL |
JESSICA GARDNER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
PATTI WIGGINS |
pwiggins@npdodge.com |
SELF |
VILLISCA |
MONTGOMERY |
IA |
NATHAN HULL |
JESSICA GARDNER |
Signed |
915 |
2022-02-15 16:43 |
Anonymous (not verified) |
199.247.79.215 |
Dale B Wetherell Trucking |
Proprietorship |
5844 40th Ave., Alta, IA 51002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-15 |
Dale Wetherell |
barbw@sppinsurance.com |
Alta |
Iowa |
Iowa |
Barbara Wetherell |
Kelli Turnquist |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dale Wetherell |
barbw@sppinsurance.com |
Self |
Alta |
Buena Vista |
IA - Iowa |
Barb Wetherell |
Kelli Turnquist |
Signed |
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 |
192 |
2020-06-24 07:42 |
Anonymous (not verified) |
66.188.136.150 |
Paul Brickley |
Proprietorship |
558 Franklin Ave. Galesburg, IL 61401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-23 |
Paul Brickley |
kschumacher@tricorinsurance.com |
Galesburg |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Brickley |
kschumacher@tricorinsurance.com |
Same |
Galesburg |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
206 |
2020-07-16 08:18 |
Anonymous (not verified) |
97.64.194.122 |
Tommy Messino |
Proprietorship |
205 S Taylor St., Cherry, IL 61317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-10 |
Tommy Messino |
kschumacher@tricorinsurance.com |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tommy Messino |
kschumacher@tricorinsurance.com |
Same |
Cherry |
Bureau |
IL |
Russell Masartis |
Shuree Behr |
Signed |
225 |
2020-08-05 14:31 |
Anonymous (not verified) |
66.188.136.150 |
William Brickley |
Proprietorship |
327 E Prairie St., Wataga, IL 61488 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-03 |
William Brickley |
kschumacher@tricorinsurance.com |
Watage |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Brickley |
kschumacher@tricorinsurance.com |
Same |
Wataga |
Knox |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
332 |
2020-12-04 10:57 |
Anonymous (not verified) |
66.188.136.150 |
Ron's Trucking LLC |
Limited Liability Company |
16007 Oak Avenue, Oak Forrest, IL 60452 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-04 |
Ronald Clark Jr. |
kschumacher@tricorinsurance.com |
Oak Forrest |
Cook |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ron's Trucking LLC |
kschumacher@tricorinsurance.com |
Same |
Oak Forrest |
Cook |
IL |
Russell Masartis |
Nancy Wortley |
Signed |
401 |
2021-02-15 14:50 |
Anonymous (not verified) |
66.188.136.150 |
Jarrod Wernimont |
Proprietorship |
24 Blackhawk Rd. Hanover, IL 61041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-12 |
Jarrod Wernimont |
kschumacher@tricorinsurance.com |
Hanover |
Jo Daviess |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jarrod Wernimont |
kschumacher@tricorinsurance.com |
Same |
Hanover |
Jo Daviess |
IL |
Russell Masartis |
Shuree Behr |
Signed |
406 |
2021-02-18 10:41 |
Anonymous (not verified) |
165.225.61.119 |
Romeo Painitng |
Proprietorship |
7 Waverly Dr Rock Island, IL 61201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-18 |
Jay Romeo |
jay.romeo12@yahoo.com |
Rock Island |
Rock Island |
IL |
Seth Rowland |
Ryan Myers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Romeo |
jay.romeo12@yahoo.com |
Self |
Rock island |
Rock Island |
IL |
Seth Rowland |
Ryan Myers |
Signed |
407 |
2021-02-18 10:47 |
Anonymous (not verified) |
165.225.61.119 |
Ryan Myers Painting |
Proprietorship |
836 25th St Rock Island, IL 61201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-21 |
Ryan Myers |
tickspoon@yahoo.com |
Rock Island |
Rock Island |
IL |
Seth Rowland |
Jay Romeo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Myers |
tickspoon@yahoo.com |
Self |
Rock Island |
Rock Island |
IL |
Seth Rowland |
Jay Romeo |
Signed |
408 |
2021-02-18 10:51 |
Anonymous (not verified) |
165.225.61.119 |
Brandon Anderson Painting |
Proprietorship |
608 30th St Rock Island, IL 61201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-21 |
Brandon Anderson |
banderson792@gmail.com |
Rock Island |
Rock Island |
IL |
Seth Rowland |
Jay Romeo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Anderson |
banderson792@gmail.com |
Self |
Rock Island |
Rock Island |
IL |
Seth Rowland |
Jay Romeo |
Signed |
431 |
2021-03-10 14:41 |
Anonymous (not verified) |
66.188.136.150 |
Brad Donovan |
Proprietorship |
1105 N 5th. Springfield, IL 62702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-10 |
Brad Donovan |
braddonovan40@gmail.com |
Springfield |
Sangamon |
IL |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brad Donovan |
braddonovan40@gmail.com |
Same |
Springfield |
Sangamon |
IL |
Russell Masartis |
Shuree Behr |
Signed |
458 |
2021-04-05 11:59 |
Anonymous (not verified) |
66.188.136.150 |
Joseph Chance |
Proprietorship |
815 Richards Dr. Shorewood, IL 60404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-29 |
Joseph Chance |
kschumacher@tricorinsurance.com |
Shorewood |
Will |
IL |
Russell Masartis |
Amanda Seeberger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph Chance |
kschumacher@tricorinsurance.com |
Same |
Shorewood |
Will |
IL |
Russell Masartis |
Amanda Seeberger |
Signed |
469 |
2021-04-12 16:49 |
Anonymous (not verified) |
65.103.82.36 |
Stice Construction |
Proprietorship |
13723 140th st W |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-07-22 |
Alex Stice |
Astice17@hotmail.com |
Taylor Ridge |
Rock Island |
IL |
Ashley Stice |
JIm Stice |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alex Stice |
astice17@hotmail.com |
self |
taylor ridge |
rock island |
il |
Ashley stice |
Jim Stice |
Signed |
473 |
2021-04-13 11:26 |
Anonymous (not verified) |
65.103.82.36 |
Quality Renovation |
Proprietorship |
1406 25th st Moline IL 61265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-06-21 |
Clarence Marvin Skipton |
marvinthemartien77@gmail.com |
Buffalo |
Scott |
IA |
Jennifer Skipton |
Rose mary Skipton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clarence Marvin Skipton |
marvinthemartien77@gmail.com |
Owner |
Moline |
Rock Island |
IL |
Jennifer skipton |
rose Skipton |
Signed |
528 |
2021-05-21 14:06 |
Anonymous (not verified) |
66.188.136.150 |
Russell Masartis |
Proprietorship |
481 Clarendon East Dubuque, IL 61025 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-21 |
Russell Masartis |
kschumacher@tricorinsurance.com |
East Dubuque |
Jo Daviess |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Russell Masartis |
kschumacher@tricorinsurance.com |
Same |
East Dubuque |
Jo Daviess |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
556 |
2021-07-07 09:16 |
Anonymous (not verified) |
66.188.136.150 |
William Campbell |
Proprietorship |
159 Friendly Blvd. Springfield, IL 62707 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-06 |
William Campbell |
kschumacher@tricorinsurance.com |
Springfield |
Sangamon |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Campbell |
kschumacher@tricorinsurance.com |
Same |
Springfield |
Sangamon |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
561 |
2021-07-08 09:11 |
Anonymous (not verified) |
66.188.136.150 |
Aaron Maldonado dba ATM Trucking |
Proprietorship |
1011 Reynolds Drive, Charleston, IL 61920 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-07 |
Aaron Maldonado dba ATM Trucking |
kschumacher@tricorinsurance.com |
Charleston |
Coles |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aaron Maldonado dba ATM Trucking |
kschumacher@tricorinsurance.com |
Same |
Charleston |
Coles |
IL |
Mitch Kemp |
Shuree Behr |
Signed |
579 |
2021-07-20 12:37 |
Anonymous (not verified) |
166.205.124.133 |
M&M HOME IMPROVEMENT |
Limited Liability Company |
5406 28th Ave. Moline , IL 61265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-07-20 |
Jarred Alexander |
bookkyddjay@gmail.com |
Moline |
USA |
IL |
Jacob Nagel |
Jacob Nagel |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jarred Alexander |
bookkyddjay@gmail.com |
Same |
Moline |
USA |
IL |
Jacob Nagel |
Jacob Nagel |
Signed |
646 |
2021-09-20 08:54 |
Anonymous (not verified) |
173.24.107.209 |
QCA Professional Contractors |
Limited Liability Company |
3314 67th Ave, Moline, IL. 61265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-20 |
Allan Celada |
allancelada@qcaprocontractors.com |
Moline |
Rock Island |
IL |
Alexander Celada |
Drexel Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Allan Celada |
allancelada@qcaprocontractors.com |
self |
Moline |
Rock Island |
IL |
Alexander Celada |
Drexel Miller |
Signed |
674 |
2021-10-15 09:43 |
Anonymous (not verified) |
173.29.63.3 |
Peter Hawley |
Proprietorship |
524 n galena ave, Wyoming Illinois 61491 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-15 |
Peter Anthony Hawley |
hawleypete801@gmail.com |
Wyoming |
Stark |
Illinois |
Elizabeth Doreen Hawley |
Ian Matthew Esmoil |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peter Anthony Hawley |
hawleypete801@gmail.com |
Self |
Wyoming |
Stark |
IL |
Elizabeth Doreen Hawley |
Ian Matthew Esmoil |
Signed |
734 |
2021-11-11 14:05 |
Anonymous (not verified) |
72.13.16.172 |
REDFEARN TRUCKING INC |
Proprietorship |
5512 WEST STAGECOACH TRAIL |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-18 |
REDFEARN TRUCKING INC |
dave@allseasonstrucking.com |
GALENA |
JODAVIES |
IL |
DAVE NEUWOHNER |
BEN MOYER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
REDFEARN TRUCKING INC |
dave@allseasonstrucking.com |
PRESIDENT |
GALENA |
JODAVIES |
IL |
DAVE NEUWOHNER |
BEN MOYER |
Signed |
751 |
2021-11-16 15:51 |
Anonymous (not verified) |
166.181.83.87 |
Dylan Wilson SMS & More |
Proprietorship |
7500 25th Milan IL 61264 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-16 |
Dylan Wilson |
doe33843@gmail.com |
Milan |
Rock Island |
IL |
Jamie Short |
Brett Dawson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jennifer Groech |
wilsoncrazy@gmail.com |
Grandmother |
Moline |
Rock Island |
IL |
Jamie Short |
Brett Dawson |
Signed |
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 |
1575 |
2023-04-16 09:00 |
Anonymous (not verified) |
94.188.205.176 |
Velocity Improvement, LLC |
Proprietorship |
PO Box 903, Wilton IA 52778 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-16 |
Kent Grunhovd |
velocityimprovement@gmail.com |
Wilton |
Scott |
Iowa |
Robin Throne |
LaVonne Grunhovd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kent Grunhovd |
kgrunhovd3535@gmail.com |
Self |
Bloomington |
McLean |
IL |
Robin Throne |
LaVonne Grunhovd |
Signed |
1830 |
2023-09-08 11:45 |
Anonymous (not verified) |
94.188.205.177 |
Bradley A Sneeden |
Proprietorship |
36 Sunset Drive, Beardstown, IL 62618 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-08 |
Bradley A Sneeden |
bradsneeden@gmail.com |
Beardstown |
Cass |
IL |
Billie Sneeden |
Dillon McNeff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bradley A Sneeden |
bradsneeden@gmail.com |
Self |
Beardstown |
Cass |
IL |
Billie Sneeden |
Dillon McNeff |
Signed |
1861 |
2023-10-05 10:14 |
Anonymous (not verified) |
94.188.207.227 |
Charles von Maur |
Proprietorship |
18325 Robbins Road Pleasant Valley IA 52767 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-05 |
Charles von Maur |
rlarsen@vonmaur.com |
Pleasant Valley |
Scott |
IA |
Robert L Larsen |
Amanda Bratthauer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert L Larsen |
rlarsen@vonmaur.com |
Outside consultant |
east moline |
Rock Island |
IL |
Josh Barnes |
Amanda Bratthauer |
Signed |
1871 |
2023-10-18 10:27 |
Anonymous (not verified) |
94.188.205.169 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kylee Lee |
Daryl Eugene Gonyier |
Signed |
1872 |
2023-10-18 10:59 |
Anonymous (not verified) |
94.188.205.177 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Eugene Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Eugene Gonyier |
Signed |
1925 |
2023-11-28 09:44 |
Anonymous (not verified) |
94.188.207.224 |
Pietro Solutions |
Limited Liability Company |
719 11th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-28 |
Ronaldo Di Pietro |
girodp@gmail.com |
Rock Island |
Rock Island |
IL |
Rita de Cássia Gallo |
Antonio Carlos Gallo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronaldo Di Pietro |
girodp@gmail.com |
Self |
Rock Island |
Rock Island |
IL |
Rita de Cássia Gallo |
Antonio Carlos Gallo |
Signed |
1951 |
2023-12-12 13:10 |
Anonymous (not verified) |
94.188.207.230 |
Patrick McGuinnis |
Limited Liability Company |
5697 Squire Circle, Thomson, IL 61285 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-09 |
Patrick A McGinnis |
McGinnistrucking2023@yahoo.com |
Thomson |
Carroll |
IL |
Ashleigh McGuinnis |
Kimberly Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Parick A McGunnis |
mcginnistrucking2023@yahoo.com |
Self |
Thomson |
Carroll |
IL |
Ashleigh McGinnis |
Kimberly Williams |
Signed |
1952 |
2023-12-12 13:26 |
Anonymous (not verified) |
94.188.205.167 |
Austin Albin |
Proprietorship |
2263 Railroad Street, Jacksonville, IL 62650 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-23 |
Austin R Albin |
albinaustin12@gmail.com |
Jacksonville |
Morgan |
IL |
Wayne Albin |
Jerry Roth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin R Albin |
albinaustin12@gmail.com |
Self |
Jacksonville |
Morgan |
IL |
Wayne Albin |
Jerry Roth |
Signed |
2199 |
2024-05-03 13:27 |
Anonymous (not verified) |
94.188.207.228 |
Polar Delights LLC DBA Twists Ice Cream |
Limited Liability Company |
110 S 9th Ave Eldridge IA 52748 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-03 |
Anna Kokity |
amkokity@gmail.com |
Moline |
Rock Island |
IL |
Ashley Schwien |
Kasey Lange |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anna Kokity |
amkokity@gmail.com |
self |
Moline |
Rock Island |
IL |
Ashley Schwien |
Kasey Lange |
Signed |
232 |
2020-08-16 11:28 |
Anonymous (not verified) |
173.27.57.39 |
Landeros & Sons Construction, Inc |
Limited Liability Partnership |
1636 19th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-16 |
Fernando Landeros |
fland1983@gmail.com |
Moline |
Rock Island |
Illinois |
Adrian Landeros |
Emanuel Landeros |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Emanuel Landeros |
fland1983@gmail.com |
Brother |
Moline |
Rock Island |
Illinois |
Adrian Landeros |
Emanuel Landeros |
Signed |
260 |
2020-09-17 10:52 |
Anonymous (not verified) |
50.80.218.18 |
Decanus Property Management |
Proprietorship |
102 E 2nd St, Davenport IA 52801 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-17 |
Shonna Suzanne Dean |
decanus@yahoo.com |
Moline |
Rock Island |
Illinois |
Justin E Proctor |
Elizabeth A Oney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shonna S Dean |
decanus@yahoo.com |
Self |
Moline |
Rock Island |
Illinois |
Justin E Proctor |
Elizabeth A Oney |
Signed |
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 |
598 |
2021-08-06 19:04 |
Anonymous (not verified) |
107.77.208.84 |
Paul Adams |
Proprietorship |
914 Bayfield drive Denton TX 76209 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-06 |
Paul T Adams |
ptadams61@yahoo.com |
Denton |
Denton |
Tx |
Jeanie Moses |
Richard Moses |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul T Adams |
ptadams61@yahoo.com |
Friends |
Milan |
Rock Island |
Illinois |
Jeanie Moses |
Richard Moses |
Signed |
647 |
2021-09-20 10:37 |
Anonymous (not verified) |
173.29.34.49 |
Brandon Jones |
Proprietorship |
2043 3x 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. |
2021-09-20 |
Brandon Dederick Jones |
Kaleb0430jones@gmail.com |
East Moline |
United States |
Illinois |
Brandon Jones |
Brandon Jones |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Dederick Jones |
Kaleb0430jones@gmail.com |
self |
East Moline |
United States |
Illinois |
Brandon Jones |
Brandon Jones |
Signed |
901 |
2022-02-06 16:48 |
Anonymous (not verified) |
50.83.154.236 |
Cole Jurgle |
Proprietorship |
409 West riverside drive prophetstown IL 61277 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-05 |
Cole Alexander Jurgle |
cole.jurgle@gmail.com |
Prophetstown |
Whiteside |
Illinois |
Nicholas Ray Jurgle |
Misty Ann Jurgle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cole Alexander Jurgle |
cole.jurgle@gmail.com |
self |
Prophetstown |
Whiteside |
Illinois |
Nicholas Ray Jurgle |
Misty Ann Jurgle |
Signed |
1008 |
2022-03-25 15:15 |
Anonymous (not verified) |
174.192.130.230 |
Hill's Rehab &Landscape L.L.C |
Limited Liability Company |
3717 15th ave Moline Illinois 61365 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-25 |
Joshua hill |
joshuajameshill79@gmail.com |
Moline |
Rock Island |
Illinois |
Lindsay erin Hill |
NICOLE ann lear |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua james hill |
joshuajameshill79@gmail.com |
President |
Moline |
Rock Island |
Illinois |
Lindsay Erin Hill |
NIcole ann lear |
Signed |
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 |
1526 |
2023-03-21 12:24 |
Anonymous (not verified) |
94.188.207.223 |
Quad Cities Transport Inc |
Proprietorship |
1106 46th ave Rock Island IL 61201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-21 |
Howard Davis |
qctranaportinc@gmail.com |
East Moline |
Rock Island |
Illinois |
Ricky Oconner |
Patrick Watkins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Howard Davis |
hdenterprisesinc14@gmail.com |
Owner |
East Moline |
Rock Island |
Illinois |
Patrick Watkins |
Ricky Oconner |
Signed |
1527 |
2023-03-22 08:35 |
Anonymous (not verified) |
94.188.205.167 |
Quad Cities Transport Inc |
Proprietorship |
1106 46th ave Rock Island IL 61201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-21 |
Howard Rick Clark Davis |
hdenterprisesinc14@gmail.com |
East Moline |
Rock Island |
IL |
Patrick Watkins |
Ricky Oconner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Howard Davis |
qctransportinc@gmail.com |
Owner |
East Moline |
Rock Island |
Illinois |
Ricky Oconner |
Patrick Watkins |
Signed |
1754 |
2023-07-19 08:52 |
Anonymous (not verified) |
94.188.207.224 |
Dustin Scoggins |
Limited Liability Company |
1723 19th ave rock island Illinois |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-19 |
Dustin Shane Scoggins |
dscoggins625@gmail.com |
Rock island |
Rock island county |
Illinois |
Emily Smith-Scoggins |
Emily Smith-Scoggins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Shane Scoggins |
dscoggins625@gmail.com |
Self |
Rock island |
Rock island county |
Illinois |
Emily Smith-Scoggins |
Emily Smith-Scoggins |
Signed |
1848 |
2023-09-19 10:20 |
Anonymous (not verified) |
94.188.207.226 |
Josh Woodworth |
Proprietorship |
16405 u.s. 67 milan il 61264 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-19 |
Josh woodworth |
joshwoodworth84@live.com |
milan |
Rock island |
Illinois |
Cody dunbar |
Jordan nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody dunbar |
cdunbar@leaffilter.com |
Install manager |
moline |
Rock island |
illinois |
Cody dunbar |
Jordan nisiewic |
Signed |
2040 |
2024-02-08 10:35 |
Anonymous (not verified) |
94.188.207.226 |
Storm Pro Solution |
Limited Liability Company |
1309 Coffeen Sheridan,wy 82801 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Candis Henderson |
Cneal@stormprosolution.com |
Broadview |
Chicago |
Illinois |
Chester Neal |
Eric Henderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Candis Henderson |
Cneal@stormprosolution.com |
Self |
Broadview |
Chicago |
Illinois |
Chester neal |
Eric Henderson |
Signed |
2160 |
2024-04-17 18:21 |
Anonymous (not verified) |
94.188.207.226 |
QC Remodeling LLC |
Limited Liability Company |
421 West Broadway, Ste 302 Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-17 |
Fernando Ibarra |
ibarra_fernando@hotmail.com |
Rock Island |
Rock Island |
Illinois |
Paula Barria |
Louis Valencia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fernando Ibarra |
ibarra_fernando@hotmail.com |
Owner |
Rock Island |
Rock Island |
Illinois |
Paula Barria |
Louis Valencia |
Signed |
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 |
2176 |
2024-04-24 11:12 |
Anonymous (not verified) |
94.188.205.176 |
Schutters Pest Control Inc. |
Limited Liability Company |
109 2nd Ave, Suite #2, Carbon Cliff,IL 61239 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-04 |
Billy Y Schutters |
schutterspestcontrol@gmail.com |
Bettendorf |
Iowa |
United States |
Aidan Sammon |
Kalissa Malin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Billy Y Schutters |
schutterspestcontrol@gmail.com |
Same Person |
Carbon Cliff |
Rock Island |
Illinois |
Aidan Sammon |
Kalissa Malin |
Signed |
2191 |
2024-04-29 10:09 |
Anonymous (not verified) |
94.188.207.225 |
Anthony Rakestraw |
Proprietorship |
1262 S Kellogg St., Galesburg, IL 61401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Anthony Rakestraw |
gazzork2@yahoo.com |
Galesburg |
Know |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Rakestraw |
gazzork2@yahoo.com |
owner |
Galesburg |
Knox |
Illinois |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
256 |
2020-09-14 09:38 |
Anonymous (not verified) |
66.188.136.150 |
Steven Headlee |
Proprietorship |
671 Metaire Drive Apt. A, Greenwood, IN 46143 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-14 |
Steven Headlee |
kschumacher@tricorinsurance.com |
Greenwood |
Johnson |
IN |
Nancy Wortley |
Russell Masartis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Steven Headlee |
kschumacher@tricorinsurance.com |
Same |
Greenwood |
Johnson |
IN |
Nancy Wortley |
Russell Masartis |
Signed |
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 |
450 |
2021-03-25 11:59 |
Anonymous (not verified) |
66.188.136.150 |
Mason Cook |
Proprietorship |
10604 Bradford Road, Indianapolis, IN 46231 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-23 |
Mason Cook |
kschumacher@tricorinsurance.com |
Indianapolis |
Marion |
IN |
Russell Masartis |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Cook |
kschumacher@tricorinsurance.com |
Same |
Indianapolis |
Marion |
IN |
Russell Masartis |
Shuree Behr |
Signed |
515 |
2021-05-11 15:18 |
Anonymous (not verified) |
66.188.136.150 |
Odie Mitchell |
Proprietorship |
10441 Serenity Dr. DeMotte, IN 46310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-05 |
Odie Mitchell |
kschumacher@tricorinsurance.com |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Odie Mitchell |
kschumacher@tricorinsurance.com |
Same |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
516 |
2021-05-12 12:41 |
Anonymous (not verified) |
66.188.136.150 |
Odie Mitchell |
Proprietorship |
10441 Serenity Dr. DeMotte, IN 46310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-05 |
Odie Mitchell |
kschumacher@tricorinsurance.com |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Odie Mitchell |
kschumacher@tricorinsurance.com |
Same |
DeMotte |
Jasper |
IN |
Shuree Behr |
Jordan Bass |
Signed |
553 |
2021-07-01 08:17 |
Anonymous (not verified) |
66.188.136.150 |
Cody Belleville |
Proprietorship |
57167 Copperdate Dr. Elkhart, IN 46516 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-30 |
Cody Belleville |
kschumacher@tricorinsurance.com |
Elkhart |
Elkhart |
IN |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Belleville |
kschumacher@tricorinsurance.com |
Same |
Elkhart |
Elkhart |
IN |
Mitch Kemp |
Shuree Behr |
Signed |
1431 |
2023-01-25 16:24 |
Anonymous (not verified) |
172.56.249.51 |
Warren transport |
Limited Liability Company |
3124 titan trail Waterloo,iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-25 |
Lamarcaus Lunford |
universalvoyager1@gmail.com |
Elkhart |
IN |
Indiana |
Quinetta shead |
Eric fikes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lamarcaus Lunford |
universalvoyager1@gmail.com |
Owner |
Elkhart |
IN |
Indiana |
Quinetta shead |
Eric fikes |
Signed |
1326 |
2022-10-04 10:27 |
Anonymous (not verified) |
70.96.153.153 |
Bright Fame Inc |
Limited Liability Company |
2185 NW 149th St, 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. |
2022-10-04 |
Robert Ferguson |
robert@optionsexteriors.com |
Clive |
Dallas |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Ferguson |
robert@optionsexteriors.com |
Owner/Self |
Clive |
Dallas |
Iosa |
Charlotte Rasmussen |
Austin Miller |
Signed |
321 |
2020-11-17 10:26 |
Anonymous (not verified) |
173.18.16.129 |
Adam Quimby |
Proprietorship |
2033 10th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-01 |
Adam Quimby |
adam.m.quimby@gmail.com |
Des Moines |
Polk |
Iowa |
Robert Coluzzi |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Quimby |
adam.m.quimby@gmail.com |
Owner |
Des Moines |
Polk |
Iow |
Robert Coluzzi |
Kelly Coluzzi |
Signed |
6 |
2019-11-14 13:09 |
Anonymous (not verified) |
69.18.10.115 |
Sigourney Heating and Air Conditioning LLC |
Limited Liability Company |
106 E Washington, Sigourney Iowa 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-14 |
Spencer A Wright |
officeshac@gmail.com |
Sigourney |
Keokuk |
Iowa |
Darren Diethelm |
Myles Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer A Wright |
officeshac@gmail.com |
Owner |
Sigourney |
Keokuk |
Iowa |
Darren Diethelm |
Myles Miller |
Signed |
7 |
2019-11-15 12:26 |
Anonymous (not verified) |
173.17.129.166 |
Thomas C. Davis |
Proprietorship |
3509 Franklin Ave, Des Moines, IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-15 |
Thomas C. Davis III |
thomas.davis.iii@gmail.com |
Des Moines |
Polk |
Iowa |
Jared Vincent |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas C. Davis III |
thomas.davis.iii@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Jared Vincent |
Kevin Corn |
Signed |
8 |
2019-12-13 12:18 |
Anonymous (not verified) |
173.18.3.76 |
Knight Electric, LLC |
Limited Liability Company |
200 E Aurora Ave, Des Moines, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-13 |
Ryan Lewis |
ryan@knightelectric.biz |
Des Moines |
Polk |
Iowa |
Angie Kinsey |
Jon Stetzel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Lewis |
ryan@knightelectric.biz |
Member/Owner |
Des Moines |
Polk |
Iowa |
Angie Kinsey |
Jon Stetzel |
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 |
14 |
2019-12-30 17:22 |
Anonymous (not verified) |
173.20.51.69 |
Rotten Love LLC |
Limited Liability Company |
1101 Valentine Drive, Dubuque Iowa 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-01-01 |
john rettenmeier |
jrettenmeier@gmail.com |
dubuque |
Dubuque |
iowa |
Carolyn Schmid |
Joe Rettenmeier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Carolyn Schmid |
jrettenmeier@gmail.com |
owner |
Dubuque |
Dubuque |
iowa |
John Rettenmeier |
John Rettenmeier |
Signed |
17 |
2019-12-31 09:24 |
Anonymous (not verified) |
72.35.186.80 |
Grgurich Dozing & Tiling, LLC |
Partnership |
PO Box 131, Williamson, IA 50272 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-31 |
Seth Grgurich |
mcbroomt15@gmail.com |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth Grgurich |
mcbroomt15@gmail.com |
Partner |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
18 |
2019-12-31 13:36 |
Anonymous (not verified) |
162.253.44.28 |
Wade Roth DBA Roth TV and Appliance |
Proprietorship |
1004 12th St, Belle Plaine, IA 52208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2019-12-09 |
Wade Roth |
WADEROTH@NETINS.NET |
Belle PLaine |
Benton |
Iowa |
Robert Sydnes |
Robert Sydnes |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wade Roth |
WADEROTH@NETINS.NET |
Self |
Belle Plaine |
Benton |
Iowa |
Robert Sydnes |
Kurt Feller |
Signed |
21 |
2020-01-01 18:16 |
Anonymous (not verified) |
72.35.186.80 |
Jerry Arnold |
Proprietorship |
1426 25th St, Humeston, IA 50123 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Jerry Arnold |
LLArnold62@gmail.com |
Humeston |
Wayne |
Iowa |
Fred Throckmorton |
Joyce Throckmorton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Arnold |
LLArnold62@gmail.com |
Self |
Humeston |
Wayne |
Iowa |
Fred Throckmorton |
Joyce Throckmorton |
Signed |
22 |
2020-01-02 14:52 |
Anonymous (not verified) |
173.17.129.166 |
Dan & Sarah Gudenkauf |
Proprietorship |
3277 180th Ave, Ryan, IA 52330 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-02 |
Sarah Gudenkauf |
dandselectricmotor@gmail.com |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Gudenkauf |
dandselectricmotor@gmail.com |
Owner |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
23 |
2020-01-02 14:54 |
Anonymous (not verified) |
173.17.129.166 |
Dan Gudenkauf |
Proprietorship |
3277 180th Ave, Ryan, IA 52330 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-02 |
Dan Gudenkauf |
dandselectricmotor@gmail.com |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Gudenkauf |
dandselectricmotor@gmail.com |
Owner |
Ryan |
Delaware |
Iowa |
Nicole Almburg |
Kevin Corn |
Signed |
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 |
25 |
2020-01-03 13:09 |
Anonymous (not verified) |
74.84.121.206 |
Raymond Jones |
Proprietorship |
P O Box 682 Monona IA 52159 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-29 |
Raymond Jones |
darrele@ciains.biz |
Monona |
Clayton |
Iowa |
Darrel J Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel J Elsbernd |
darrele@ciains.biz |
insurance agent |
Lime Springs |
Howard |
Iowa |
Darrel J Elsbernd |
Chris Fye |
Signed |
26 |
2020-01-04 17:23 |
Anonymous (not verified) |
45.53.67.52 |
Gary De Jager |
Limited Liability Company |
417 florida Ave NW Orange City Iowa 51041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-04 |
Gary Dean De Jager |
mightyspear60@yahoo.com |
Orange City |
Souix |
Iowa |
Brody Dean De Jager |
Tyler Ray De Jager |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Dean De Jager |
mightyspear60@yahoo.com |
owner |
Orange City |
souix |
Iowa |
Brody Dean De Jager |
Tyler Ray De Jager |
Signed |
29 |
2020-01-06 13:44 |
Anonymous (not verified) |
108.178.203.226 |
MULLIS CATTLE LLC |
Limited Liability Company |
2506 155TH ST, EARLVILLE IA 52041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
DAVID MULLIS |
JAMES@CIOIA.COM |
EARLVILLE |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DAVID MULLIS |
JAMES@CIOIA.COM |
OWNER |
EARLVILLE |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
31 |
2020-01-07 08:37 |
Anonymous (not verified) |
199.10.5.7 |
Data Information Management LLC |
Limited Liability Company |
703 Bluff St Dubuque IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-07 |
Christopher R Broessel |
chris@caricomm.com |
Dubuque |
Dubuque |
IA |
Janet L Schauff |
Morris P Schauff |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephen M schauff |
steve@caricomm.com |
Partner |
Dubuque IA |
Dubuque |
Iowa |
Janet L schauff |
Morris P Schauff |
Signed |
32 |
2020-01-08 08:31 |
Anonymous (not verified) |
199.120.118.90 |
BOBCATS LLC |
Limited Liability Company |
1860 505TH ST LINN GROVE IOWA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-18 |
CHRIS AXDAHL |
CHRISAXDAHLINC@HOTMAIL.COM |
LINN GROVE |
CLAY |
IOWA |
TESSA L STEFFEN |
JOSEPH E ZENKOVICH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CHRIS AXDAHL |
CHRISAXDAHLINC@HOTMAIL.COM |
OWNER |
LINN GROVE |
CLAY |
IOWA |
TESSA L STEFFEN |
JOSEPH E ZENKOVICH |
Signed |
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 |
35 |
2020-01-13 13:23 |
Anonymous (not verified) |
173.28.28.57 |
Milkhouse Market, LLC |
Limited Liability Company |
911 Parriott Street, Aplington IA 50604 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-30 |
MARY MEYER |
cmins_re@mchsi.com |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MARY MEYER |
cmins_re@mchsi.com |
Self |
Aplington |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
36 |
2020-01-15 13:26 |
Anonymous (not verified) |
173.28.28.57 |
Shirley Pepples |
Proprietorship |
206 4th Street, Parkersburg, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-14 |
Shirley Pepples |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shirley Pepples |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
37 |
2020-01-16 15:26 |
Anonymous (not verified) |
173.24.236.134 |
Eric Krueger |
Proprietorship |
406 NE Oak Dr. Ankeny, IA 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-16 |
Eric Lucas Krueger |
erickrugs@gmail.com |
Ankeny |
Polk |
Iowa |
Emily Marie Krueger |
Roberty William Krueger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Krueger |
erickrugs@gmail.com |
self |
Ankeny |
Polk |
Iowa |
Emily Marie Krueger |
Robert William Krueger |
Signed |
38 |
2020-01-18 12:15 |
Anonymous (not verified) |
206.109.174.199 |
BJS Frenchies, LLC |
Limited Liability Company |
20081 Highway J 46 Centerville Iowa 52544 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
J. Jamie Tracy |
jamiespuppies@yahoo.com |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce E Tracy |
jamiespuppies@yahoo.com |
Husband and Co Owner |
Centerville |
Appanoose |
Iowa |
Misty O'Hair |
Casey Leach |
Signed |
43 |
2020-01-27 09:23 |
Anonymous (not verified) |
71.199.85.251 |
ATW Training |
Limited Liability Company |
4414 114th Street, Urbandale Iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-25 |
Heather Hampton Cooper |
hcooper1@comcast.net |
Saint Augustine |
Saint Johns |
Florida |
Terry Lee Cooper |
Stacy Thatcher |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lynn Roberts |
Lynne@atwtraining.com |
HR |
Des Moines |
Polk |
Iowa |
Cathy Belmont |
Mark Purcell |
Signed |
45 |
2020-01-28 16:13 |
Anonymous (not verified) |
173.18.3.76 |
Delic Marble and Tile LLC |
Limited Liability Company |
24 Ellefson Dr PO Box 413 DeSoto, IA 50069 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-31 |
Adin Delic |
delicgraniteandtile@gmail.com |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lutfija Delic |
delicgraniteandtile@gmail.com |
LLC Member |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
46 |
2020-01-28 16:32 |
Anonymous (not verified) |
173.18.3.76 |
Delic Marble and Tile LLC |
Limited Liability Company |
24 Ellefson Dr PO Box 413 DeSoto, IA 50069 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2020-01-27 |
Lutfija Delic |
delicgraniteandtile@gmail.com |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adin Delic |
delicgraniteandtile@gmail.com |
LLC Member |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
47 |
2020-01-28 16:35 |
Anonymous (not verified) |
173.18.3.76 |
Delic Marble and Tile LLC |
Limited Liability Company |
24 Ellefson Dr PO Box 413 DeSoto, IA 50069 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-27 |
Sabahudin Delic |
delicgraniteandtile@gmail.com |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adin Delic |
delicgraniteandtile@gmail.com |
LLC Member |
Adel |
Dallas |
Iowa |
Angela Kinsey |
Taylor Benshoof |
Signed |
48 |
2020-01-29 13:52 |
Anonymous (not verified) |
97.64.170.98 |
DARIN J. KESSLER |
Proprietorship |
1236 25TH ST AMES, IA 50010 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-29 |
DARIN J. KESSLER |
darinjkessler@gmail.com |
AMES |
STORY |
IOWA |
HEATHER DIANNE LANNING |
JENNY ANN ARENDS |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DARIN J. KESSLER |
darinjkessler@gmail.com |
SELF |
AMES |
STORY |
IOWA |
HEATHER DIANNE LANNING |
JENNY ANN ARENDS |
Signed |
49 |
2020-01-31 12:53 |
Anonymous (not verified) |
74.84.121.206 |
Cody Kleppe |
Proprietorship |
1891 337th St Decorah IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-31 |
Cody Kleppe |
darrele@ciains.biz |
Decorah |
Winneshiek |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Decorah |
Winneshiek |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
50 |
2020-02-03 14:55 |
Anonymous (not verified) |
173.28.28.57 |
Silverleaf Capital, LLC |
Limited Liability Company |
1606 Palmer Court, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-20 |
Silverleaf Capital, LLC |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Silverleaf Capital, LLC |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
51 |
2020-02-04 10:31 |
Anonymous (not verified) |
173.28.28.57 |
Sister Style, LLC |
Limited Liability Company |
211 3rd Street, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-23 |
Lisa Ellis |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lisa Ellis |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
52 |
2020-02-04 10:35 |
Anonymous (not verified) |
173.28.28.57 |
Sister Style, LLC |
Limited Liability Company |
211 3rd Street, Parkersburg IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-23 |
Amanda Jorgenson |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Amanda Jorgenson |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
54 |
2020-02-06 14:18 |
Anonymous (not verified) |
173.28.28.57 |
Dale Hansman dba Klinkenborg Hansmann Law Office |
Proprietorship |
1201 Hwy 57, Parkersburg, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-14 |
Dale Hansmann |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dale Hansmann |
cmins_re@mchsi.com |
Self |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
57 |
2020-02-10 15:33 |
Anonymous (not verified) |
198.167.182.164 |
AllEnhancements LLC |
Limited Liability Company |
1122 Woodland Ln, LeClaire, IA 52753 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-31 |
Brett Allen |
allenhancementsllc@outlook.com |
LeClaire |
Scott |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brett Allen |
allenhancementsllc@outlook.com |
Managing Member |
LeClaire |
Scott |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
58 |
2020-02-10 21:18 |
Anonymous (not verified) |
75.162.11.63 |
Moni tile Services llc |
Limited Liability Company |
2207 E Walnut St des Moines iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-01 |
Monica M Sandoval |
Mjsandoval20@yahoo.com |
Des Moines |
Polk |
United States |
Cassie Ann bentz |
James wesley harkert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Moni tile services llc |
Mjsandoval20@yahoo.com |
Self |
Des Moines |
Polk |
Iowa |
Cassie Ann bentz |
James wesley harkert |
Signed |
59 |
2020-02-11 11:34 |
Anonymous (not verified) |
198.167.182.164 |
Besch Electric LLC |
Limited Liability Company |
317 Sycamore St, Riverside, IA 52327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-03 |
Daniel Besch |
beschd@hotmail.com |
Riverside |
Washington |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Besch |
beschd@hotmail.com |
Managing Member |
Riverside |
Washington |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
60 |
2020-02-12 10:10 |
Anonymous (not verified) |
198.167.182.164 |
Sara Torres |
Proprietorship |
419 Lilac St, Tiffin, IA 52340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-11 |
Sara Torres |
skb_blue08@hotmail.com |
Tiffin |
Johnson |
Iowa |
Steven J Fishman |
E. Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sara Torres |
skb_blue08@hotmail.com |
Owner |
Tiffin |
Johnson |
Iowa |
Steven J Fishman |
E Dyan Kriener |
Signed |
62 |
2020-02-17 06:55 |
Anonymous (not verified) |
173.31.111.29 |
Pa's Construction LLC |
Limited Liability Company |
2350 Glass Rd NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-17 |
Gregory Daniel Saunders |
gsaunders.pas@gmail.com |
CEDAR RAPIDS |
IOWA |
United States |
Laura Sturm |
Chad Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Saunders |
dan2112411@yahoo.com |
Owner |
Cedar Rapids |
Linn |
Iowa |
Walt Cheney |
Mike Broghammer |
Signed |
64 |
2020-02-18 10:02 |
Anonymous (not verified) |
198.167.182.164 |
Elite Electrical Service LLC |
Limited Liability Company |
2035 Lynncrest Dr, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-18 |
Sean Brogan |
brogan_sean@hotmail.com |
Coralville |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sean Brogan |
brogan_sean@hotmail.com |
Managing Member |
Coralville |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
66 |
2020-02-19 08:48 |
Anonymous (not verified) |
170.232.227.246 |
CRS Inc |
Proprietorship |
1442 3rd Ave SW Belmond, IA 50421 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
Rebecca Gardner |
beckygard1018@gmail.com |
Waverly |
Bremer |
Iowa |
Sarah Lowe |
Kelsey Poe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rebecca Gardner |
beckygard1018@gmail.com |
Consultant |
Waverly |
Bremer |
Iowa |
Sarah Lowe |
Kelsey Poe |
Signed |
67 |
2020-02-19 10:16 |
Anonymous (not verified) |
198.167.182.164 |
AWF579 LLC |
Limited Liability Company |
13 Lynden Dr NE, Iowa City, IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-18 |
Jeffrey Schiltz |
jeffschiltz2@yahoo.com |
Iowa City |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeffrey Schiltz |
jeffschiltz2@yahoo.com |
Managing Member |
Iowa City |
Johnson |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
68 |
2020-02-19 12:00 |
Anonymous (not verified) |
198.14.241.59 |
SIERRA ROOFING LLC |
Limited Liability Company |
909 N ELM ST WEST LIBERTY IA 52776 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
ABRAHAM GRANJENO |
SIERRA89@GMAIL.COM |
WEST LIBERTY |
MUSCATINE |
IOWA |
JOSE SALGADO |
ALEJANDRIA FRAUSTO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ABRAHAM GANJENO |
SIERRA89@GMAIL.COM |
OWNER |
WEST LIBERTY |
MUSCATINE |
IOWA |
JOSE SALGADO |
ALEJANDRIA FRAUSTO |
Signed |
69 |
2020-02-19 15:58 |
Anonymous (not verified) |
198.14.241.59 |
MORENOS C ROOFING LLC |
Limited Liability Company |
2018 WATERFRONT DR LOT 73 IOWA CITY IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-19 |
RAQUEL OLEA CAMACHO |
JORGETREJO19896@GMAIL.COM |
IOWA CITY |
JOHNSON |
IOWA |
JORGE TREJO |
JOSE SALGADO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RAQUEL OLEA CAMACHO |
JORGETREJO19896@GMAIL.COM |
OWNER |
IOWA CITY |
JOHNSON |
IOWA |
JORGE TREJO |
JOSE SALGADO |
Signed |
72 |
2020-02-21 09:43 |
Anonymous (not verified) |
98.18.174.183 |
Forrest E. Whitford DVM LLC |
Limited Liability Company |
P.O. Box 120 - 507 Washington Street, Volga, IA 52077 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-21 |
Forrest E. Whitford, DVM LLC |
gfw54@hotmail.com |
Volga, IA |
Clayton |
Iowa |
Glenna Whitford |
Pam Vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Forrest E. Whitford, DVM LLC |
gfw54@hotmail.com |
self |
Volga |
Clayton |
Iowa |
Glenna Whitford |
Pam Vaske |
Signed |
73 |
2020-02-21 13:44 |
Anonymous (not verified) |
192.30.185.233 |
Viejos Masnry construction LLC |
Limited Liability Company |
1708 Villa Ave. Sioux City IA 51103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-13 |
Oscar Castro Ramirez |
veijosconstruction@gmail.com |
Sioux City |
Woodbury |
Iowa |
JEFFREY H MCCLINTOCK |
Nancy Fleming |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Viejos Masonry Construction LLC |
veijosconstruction@gmail.com |
Owner/President |
SIOUX CITY |
Woodbury |
Iowa |
Nancy Fleming |
Jeffrey Hugh McClintock |
Signed |
74 |
2020-02-24 15:00 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Ramiro Jurado Gomez |
Liberty21424@gmail.com |
Des Moines |
Polk |
IA |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
75 |
2020-02-24 15:03 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Ramiro Jurado Bucio |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valerie Cramer |
cramerlaw@halousa.com |
Attorney |
Des Moines |
Polk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
76 |
2020-02-24 15:05 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Angel Jurado |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
Valerie Cramer |
David Murray |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cramer Law PLC |
cramerlaw@halousa.com |
Attorney |
Polk |
Polk |
Iowa |
Sara Mc Ginnis |
David Murray |
Signed |
77 |
2020-02-24 15:07 |
Anonymous (not verified) |
97.64.133.18 |
Sky Roofing LLC |
Partnership |
1332 Idaho St., Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-01 |
Victor Jurado |
Liberty21424@gmail.com |
des moines |
Polk |
Iowa |
David Murray |
Valerie Cramer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cramer Law PLC |
Liberty21424@gmail.com |
Attorney |
DES MOINES |
POlk |
Iowa |
David Murray |
Sara McGinnis |
Signed |
83 |
2020-02-28 12:55 |
Anonymous (not verified) |
204.16.58.27 |
Baltes Trucking LLC |
Limited Liability Company |
203 N Gilmore Ave New Hampton IA 50659 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-28 |
Clinton Lee Baltes |
clintbaltes@gmail.com |
New Hampton |
Chickasaw |
Iowa |
Tammy Robinson |
Richard Kramer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clinton Lee Baltes |
clintbaltes@outlook.com |
Owner |
New Hampton |
Chickasaw |
Iowa |
Tammy Robinson |
Richard Kramer |
Signed |
84 |
2020-02-28 15:30 |
Anonymous (not verified) |
198.167.182.164 |
Rid-A-Bird Inc. |
Limited Liability Company |
3116 Friendship St. Iowa City IA 52245 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-28 |
Keith Wilson |
kwilson@windowgenie.com |
Iowa City |
Johnson |
Iowa |
Dyan Kriener |
Marcia A Colvin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith Wilson |
kwilson@windowgenie.com |
Managing member |
Iowa City |
Johnson |
Iowa |
Dyan Kriener |
Marcia A Colvin |
Signed |
85 |
2020-03-09 08:17 |
Anonymous (not verified) |
198.167.182.164 |
Simply Anchored LLC dba Simply Mae's |
Limited Liability Company |
601 Broad St, Story City, IA 50248 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-05 |
Jessi Kettenacker |
jessi@simplymaes.com |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jessi Kettenacker |
jessi@simplymaes.com |
Managing Member |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
86 |
2020-03-09 08:19 |
Anonymous (not verified) |
198.167.182.164 |
Simply Anchored LLC dba Simply Mae's |
Limited Liability Company |
601 Broad St, Story City, IA 50248 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-05 |
Cande Coulter |
cande@simplymaes.com |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Candy Coulter |
cande@simplymaes.com |
Managing Member |
Story City |
Story |
Iowa |
Lynn McKinney |
Dyan Kriener |
Signed |
90 |
2020-03-13 15:44 |
Anonymous (not verified) |
173.24.190.134 |
Heath Householder |
Limited Liability Company |
2 N Huron Street, Emmetsburg IA 50536 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-07 |
Heath Householder |
heath679@live.com |
Emmetsburg |
Palo Alto |
Iowa |
Scott Wirtz |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath Householder |
heath679@live.com |
Member of LLC |
Emmetsburg |
Palo Alto |
Iowa |
Scott Wirtz |
Candie Clark |
Signed |
91 |
2020-03-13 15:51 |
Anonymous (not verified) |
173.24.190.134 |
Small Town RV, LLC |
Limited Liability Company |
112 Miller Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-09 |
Heath Sabin |
sales@smalltownrv.com |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath Sabin |
sales@smalltownrv.com |
Member of LLC |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
92 |
2020-03-13 15:53 |
Anonymous (not verified) |
173.24.190.134 |
Tammy Sabin |
Limited Liability Company |
112 Miller Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-09 |
Tammy Sabin |
sales@smalltownrv.com |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tammy Sabin |
sales@smalltownrv.com |
Member of LLC |
Mallard |
Palo Alto |
Iowa |
Dave Walters |
Candie Clark |
Signed |
93 |
2020-03-16 08:01 |
Anonymous (not verified) |
174.217.14.119 |
DOUBLE J CONTRACTING LLC |
Limited Liability Company |
18693 335TH LN, EARLHAM, IA 50072 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-16 |
JOSHUA D OSCARSON |
double-j-llc@outlook.com |
EARLHAM |
DALLAS |
IOWA |
Tim Hudson |
Kevin Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas Oscarson |
double-j-llc@outlook.com |
Business Manager |
Earlham |
Dallas |
Iowa |
Tim Hudson |
Kevin Gomez |
Signed |
95 |
2020-03-18 14:47 |
Anonymous (not verified) |
173.24.186.251 |
Layton C. Vick II dba Layton's Backhoe Service |
Proprietorship |
PO Box 652 / Spirit Lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-18 |
Layton Clarence VIck II |
lcvii2@gmail.com |
Lake Park |
Dickinson |
Iowa |
Daniel Reimers |
Marcus VanKleek |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Layton C. Vick II |
lcvii2@gmail.com |
Owner |
Lake Park |
Dickinson |
Iowa |
Daniel Reimers |
Marcus VanKleek |
Signed |
97 |
2020-03-21 12:05 |
Anonymous (not verified) |
173.22.82.137 |
JHK Construction LLC |
Limited Liability Company |
6203 Casey Court NE Cedar Rapids, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-21 |
Edward Charles Loehr |
jhkconstruction10@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Brandon Peters |
Mandy Mason |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edward Charles Loehr |
jhkconstruction10@gmail.com |
Owner |
6203 Casey Court NE |
Linn County |
Iowa |
Brandon Peters |
Mandy Mason |
Signed |
100 |
2020-03-24 15:46 |
Anonymous (not verified) |
216.51.130.87 |
Lake City Electric, LLC |
Limited Liability Company |
113 E Main Street, Lake City, IA 51449 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-24 |
Lonnie R. Daisy |
lcelectric@iowatelecom.net |
Lake City |
Calhoun |
IOWA |
Sheryl Lynch |
Karen Prebeck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lonnie R. Daisy |
lcelectric@iowatelecom.net |
self |
Lake City |
Calhoun |
IOWA |
Sheryl Lynch |
Karen Prebeck |
Signed |