540 |
2021-06-08 21:40 |
Anonymous (not verified) |
50.83.39.243 |
Brightland Appraisal Group |
Limited Liability Company |
1348 Rolling Glen Dr. Marion IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-08 |
Eric Lamp |
eric.lamp@brightlandappraisal.com |
Marion |
Linn |
Iowa |
Sarah Lamp |
Linda Lamp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Allen Lamp |
eric.lamp@brightlandappraisal.com |
Self |
Marion |
Linn |
Iowa |
Sarah Lamp |
Linda Lamp |
Signed |
652 |
2021-09-22 21:52 |
Anonymous (not verified) |
209.152.66.250 |
Robert Stutzman |
Limited Liability Company |
33784 Hwy 22 Keota, IA 25548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-22 |
Robert L Stutzman |
bnbstutzman@gmail.com |
Keota |
Keokuk |
Iowa |
Jo Edgington |
Amber Gent |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sandra K Stutzman |
iafarmgirl90@gmail.com |
Daughter |
Keota |
Keokuk |
Iowa |
Jo Edgington |
Amber Gent |
Signed |
764 |
2021-11-22 15:33 |
Anonymous (not verified) |
198.14.219.227 |
Central Iowa Painting and Contracting LLC |
Limited Liability Company |
408 Freel Drive, Ste. 101, Ames, IA 50010 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Matthew Paul Klucas |
mklucas50@gmail.com |
Fort Dodge |
Webster County |
Iowa |
Jordan Watkins |
Scott Schuler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Klucas |
mklucas50@gmail.com |
Owner of Buisness |
Fort Dodge |
Webster County |
Iowa |
Jordan Watkins |
Scott Schuler |
Signed |
876 |
2022-01-31 11:31 |
Anonymous (not verified) |
75.162.226.236 |
Leaf Fitters |
Limited Liability Company |
16180 SE Laurel St Des Moines Ia 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-31 |
Rogelio De La Rosa Jr. |
chucotx@rocketmail.com |
Des Moines |
Polk |
Iowa |
Noreen Henry |
Christian Lopez |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Rogelio De La Rosa |
chucotx@rocketmail.com |
self |
Des Moines |
polk |
ia |
noreen henry |
Christian Lopez |
Signed |
923 |
2022-02-17 12:49 |
Anonymous (not verified) |
173.22.55.191 |
Fat Bus |
Limited Liability Company |
1730 All State Ct. Suite 100 West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Victor Holzworth |
holzconstruction@gmail.com |
Waukee |
Dallas |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Victor Holzworth |
holzconstruction@gmail.com |
Owner |
West Des Moines |
Polk |
Iowa |
Brandon Pratt |
Mariah Burgett |
Signed |
1035 |
2022-04-05 12:03 |
Anonymous (not verified) |
199.120.121.97 |
Bruce Peters Painting |
Proprietorship |
53568 Rosewood Road, Walnut IA 51577 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
Bruce Peters |
bpeters1992@yahoo.com |
Walnut |
Pottawattamie |
Iowa |
Marie Peters |
Angie Gettys |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bruce Peters |
bpeters1992@yahoo.com |
self |
Walnut |
Pottawattamie |
Iowa |
Marie Peters |
Angie Gettys |
Signed |
1834 |
2023-09-08 15:04 |
Anonymous (not verified) |
94.188.205.177 |
Ryan Tucker |
Proprietorship |
19000 hwy 69 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-08 |
Ryan Tucker |
rtlltucker@yahoo.com |
Indianola |
Warren |
Iowa |
Brooke Prior |
Aly Brose |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Tucker |
rtlltucker@yahoo.com |
Officer |
Indianola |
Warren |
Iowa |
Brooke Prior |
Aly Brose |
Signed |
1147 |
2022-06-08 11:29 |
Anonymous (not verified) |
67.55.184.250 |
Morgan Anderson |
Proprietorship |
23379 120th Ave, Mediapolis, IA 52637 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-08 |
Morgan Duane Anderson |
morgananderson6.ma@gmail.com |
Mediapolis |
IA |
United States |
Kelly S Lanz |
Monte A Lanz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Morgan D. Anderson |
morgananderson6.ma@gmail.com |
sole proprietor |
Mediapolis |
Louisa |
Iowa |
Kelly Lanz |
Monte Lanz |
Signed |
1946 |
2023-12-06 16:51 |
Anonymous (not verified) |
94.188.205.168 |
Blue Sky Renovations Iowa LLC |
Limited Liability Company |
2059 Lyon St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sell Now Iowa |
team@sellnowiowa.com |
None |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
1259 |
2022-08-15 13:47 |
Anonymous (not verified) |
173.29.47.222 |
Premiere Plastering & Drywall, Inc. |
Proprietorship |
2331 W. 63rd St., Davenport, IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-15 |
Johnathan Scott |
karma27895@gmail.com |
East Moline |
Rock Island |
Illinois |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
2058 |
2024-02-26 16:32 |
Anonymous (not verified) |
94.188.207.224 |
performance gutter |
Proprietorship |
PO BOX 306, NORWALK IOWA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-26 |
RICHARD BAINTER |
RWBNJ50@AOL.COM |
NORWALK |
WARREN |
IOWA |
DYLAN LANE |
JAMES LANE |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RICHARD BAINTER |
RWBNJ50@AOL.COM |
OWNER |
NORWALK |
WARREN |
IOWA |
DYLAN LANE |
JAMES LANE |
Signed |
1371 |
2022-11-14 10:55 |
Anonymous (not verified) |
166.181.86.95 |
Dean Abramczak |
Proprietorship |
524 Nodaway Dr center Point Iowa 52213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-16 |
Dean Abramczak |
gabramczak@gmail.com |
Center Point |
IA |
United States |
Brenda Oconner |
Kenny McGraw |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dean Abramczak |
gabramczak@gmail.com |
I am the only employee I own the company |
Center Point |
IA |
United States |
Brenda Oconnner |
Kenny McGraw |
Signed |
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 |
1483 |
2023-02-25 14:57 |
Anonymous (not verified) |
94.188.205.168 |
Van Wyk Lawn Services |
Limited Liability Company |
14486 S. 128th ave E. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-24 |
Anthony Eugene Van Wyk |
vanwykturf@gmail.com |
Lynnville |
Iowa |
United States |
Ashley Lynn Van Wyk |
Abby Christine Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony Eugene Van Wyk |
vanwykturf@gmail.com |
Self/Owner |
Lynnville |
Iowa |
United States |
Ashley Lynn Van Wyk |
Abby Christine Peterson |
Signed |
108 |
2020-04-01 16:50 |
Anonymous (not verified) |
206.72.23.71 |
Heartland Renovations, LLC |
Limited Liability Company |
50253 290th Street, Kelley, IA 50134 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-01 |
Troy Van Maaren |
almostanything2@gmail.com |
Kelley |
Iowa |
United States |
Tammy J Reid |
Todd L Greenslit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Troy Van Maaren |
almostanything2@gmail.com |
Member |
Kelley |
Story |
Iowa |
Tammy J Reid |
Todd L Greenslit |
Signed |
1595 |
2023-04-24 12:34 |
Anonymous (not verified) |
94.188.205.166 |
Ankeny & Neighbors |
Proprietorship |
603 South St, Cambridge Iowa 50046 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-24 |
William Richard Borchard III |
william@damageddevicerepair.com |
Cambridge |
Story |
Iowa |
Heather Borchard |
Mark Densmond |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Borchard III |
william@damageddevicerepair.com |
Sole proprietor/owner |
Cambridge |
Story |
Iowa |
Heather Borchard |
Mark Densmore |
Signed |
220 |
2020-08-02 13:45 |
Anonymous (not verified) |
99.203.112.113 |
R&G SEAMLESS GUTTERS |
Proprietorship |
3244 Dubuque Ave, 3244 Dubuque Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-02 |
Ruben Munoz Haro |
munozharoruben@gmail.com |
Des Moines |
Polk |
Estados Unidos |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ruben Munoz- R&G SEAMLESS GUTTERS |
Munozharoruben@gmail.com |
owner |
3244 Dubuque Ave Des Moines Iowa 50317 |
polk |
iowa |
Gabriel Ramirez |
Adriana Ramirez |
Signed |
1707 |
2023-06-25 10:39 |
Anonymous (not verified) |
94.188.207.224 |
Michael D Ray |
Proprietorship |
4944 Holcomb Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
Michael D Ray Jr |
mdray01@msn.com |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael D Ray |
mdray01@msn.com |
Owner Proprietor |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
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 |
444 |
2021-03-22 16:26 |
Anonymous (not verified) |
207.191.204.10 |
Robert G. Wright Jr, |
Proprietorship |
2721 Elm St Dubuque, IA 52001 PO Box 475 Dubuque, IA 52004 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-20 |
Robert G. Wright Jr, |
robertw1963@gmail.com |
Dubuque |
Dubuque |
Iowa |
Brian Kregal |
Lynda Howell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert G. Wright Jr, |
robertw1963@gmail.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Brian Kregel |
Lynda Howell |
Signed |
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 |
668 |
2021-10-12 16:11 |
Anonymous (not verified) |
173.18.22.217 |
Mo's Cleaning LLC |
Limited Liability Company |
1412 E 23rd St Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-12 |
Melissa Jones |
commcleanwithme123@gmail.com |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Jones |
commcleanwithme123@gmail.com |
Owner |
Des Moines |
Polk |
IA |
Kelly Coluzzi |
Lesa Reeves |
Signed |
780 |
2021-12-06 10:45 |
Anonymous (not verified) |
172.83.21.144 |
Munn Enterprises LLC |
Limited Liability Company |
118 14th Avenue South |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-06 |
Troy T Munn |
Troy@munnentllc.con |
Clear lake |
Cerro Gordo |
Iowa |
Douglas A Munn |
Marjorie Marie Munn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Troy Thomas Munn |
troy@munnentllc.com |
Same |
Clear Lake |
Cerro Gordo |
Iowa |
Douglas A Munn |
Marjorie Marie Munn |
Signed |
939 |
2022-02-28 13:46 |
Anonymous (not verified) |
173.23.228.17 |
H & T Ziesman, LLC |
Limited Liability Company |
575 Nuthatch Iowa Falls IA 50126 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-28 |
Heath Ziesman |
heathziesman87@gmail.com |
Iowa Falls |
Franklin |
Iowa |
Jeanne Rieks |
Kelly Reed |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath ZIesman |
heathziesman87@gmail.com |
Owner |
Iowa Falls |
Franklin |
Iowa |
Jeanne Rieks |
Kelly Reed |
Signed |
1051 |
2022-04-14 17:56 |
Anonymous (not verified) |
199.59.236.46 |
Triple M Welding |
Proprietorship |
407 4th St Sw |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Matthew Gibson |
matthew.gibson02003@gmail.com |
Independence |
Iowa |
Iowa |
Brandon Keener |
Cody Laughlin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Gibson |
matthew.gibson02003@gmail.com |
Owner |
Independence |
Iowa |
Iowa |
Brandon Keener |
Cody Laughlin |
Signed |
1850 |
2023-09-20 16:28 |
Anonymous (not verified) |
94.188.207.225 |
JB DOCK SERVICE |
Limited Liability Company |
1313 34TH ST SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-20 |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JONATHON BRUNSVOLD |
jbdockservice@gmail.com |
SELF |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1163 |
2022-06-23 09:17 |
Anonymous (not verified) |
74.84.106.106 |
James Chitty |
Proprietorship |
307 2nd St Colo, Ia 50056 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-23 |
James Chitty |
techsupport@smartind.com |
Colo |
Story |
IA |
Tina Owens |
Kim Owens |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Chitty |
techsupport@smartind.com |
self |
Colo |
Story |
IA |
Tina Owens |
Kim Owens |
Signed |
1962 |
2023-12-17 18:48 |
Anonymous (not verified) |
94.188.207.223 |
HGC Homes LLC |
Limited Liability Company |
6795 NE Rising Sun Dr Pleasant Hill, IA 50327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-17 |
Nicholas T Campbell |
hgchomes@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Kaut |
michael@rbadesmoines.com |
None |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
1275 |
2022-08-19 13:40 |
Anonymous (not verified) |
173.29.47.222 |
Premiere Plastering & Drywall, Inc. |
Proprietorship |
2331 W. 63rd St., Davenport, IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-19 |
Jonas Martinez |
jonasmartinez0202@icloud.com |
Iowa City |
Johnson |
Iowa |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Scott |
Iowa |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
2074 |
2024-03-04 16:56 |
Anonymous (not verified) |
94.188.207.224 |
IG painting Llc |
Limited Liability Company |
416 51st ST West des moines,IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-01 |
antonio J Iglesias |
antonio_joserene@hotmail.com |
west Des moines |
polk |
iowa |
Raul Gomez |
Bruno Cruz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Antonio J Iglesias |
antonio_joserene@hotmail.com |
not relationship |
West des Moines |
polk |
iowa |
Raul Gomez |
Bruno cruz |
Signed |
1387 |
2022-12-10 22:39 |
Anonymous (not verified) |
98.156.163.144 |
Springfield Staffing Solution |
Limited Liability Company |
14918 Tuff Rd, Manor TX 78653 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-10 |
Beluchukwu Ebede |
admin@springfield-staffing.com |
Manor |
Travis |
United States |
Oluchukwu Nwokoye |
Beluchukwu Ebede |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beluchukwu Ebede |
admin@springfield-staffing.com |
Self |
Manor |
Travis |
United States |
Oluchukwu Nwokoye |
Beluchukwu Ebede |
Signed |
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 |
2186 |
2024-04-28 11:12 |
Anonymous (not verified) |
94.188.205.168 |
John Martin |
Proprietorship |
1378 60th avenue Blue Grass 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. |
2024-04-28 |
John D Martin |
martinflooring@netzero.com |
Blue Grass |
Muscatine |
Iowa |
John D Martin |
John D Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John D Martin |
martinflooring@netzero.com |
Owner |
Blue Grass |
Muscatine |
Iowa |
John D Martin |
John D Martin |
Signed |
1499 |
2023-03-07 11:21 |
Anonymous (not verified) |
94.188.205.177 |
Ryan Zimmerman |
Proprietorship |
17606 35th St Lime Springs, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-27 |
Ryan Zimmerman |
darrele@ciains.biz |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Lime Springs |
Howard |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
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 |
1611 |
2023-04-27 09:21 |
Anonymous (not verified) |
94.188.205.168 |
powell express moving |
Proprietorship |
2600 Marquette Pl Dubuque, IA 52001 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-27 |
Roger Powell |
powellexpressmoving@gmail.com |
Dubuque |
Dubuque |
Iowa |
Connie Powell |
Jay Weiser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roger Powell |
powellexpressmoving@gmail.com |
Self |
Dubuque |
Dubuque |
Iowa |
Connie Powell |
Jay Weiser |
Signed |
236 |
2020-08-18 16:15 |
Anonymous (not verified) |
173.28.28.57 |
Michael Ballhagen |
Proprietorship |
279 Pine Street, Allison IA 50602 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-07 |
Michael Ballhagen |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Ballhagen |
cmins_re@mchsi.com |
Self |
Allison |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
1723 |
2023-07-06 11:50 |
Anonymous (not verified) |
94.188.205.175 |
Doug Ferneding |
Proprietorship |
21618 270th St. Carroll, IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-06 |
Doug Ferneding |
dougferneding@gmail.com |
Carroll |
Carroll |
Iowa |
Brenda Klein |
Kyle Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Doug Ferneding |
dougferneding@gmail.com |
same |
Carroll |
Carroll |
Iowa |
Brenda Klein |
Kyle Klein |
Signed |
348 |
2020-12-31 14:09 |
Anonymous (not verified) |
66.129.217.166 |
Premier Plus LLC |
Limited Liability Company |
1930 St Andrews Crt NE, Suite A, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
Cerby Newton |
tonypauljohnson@yahoo.com |
Cedar Rapids |
IA |
United States |
Olvin Lanza |
Anthony Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cerby Newton |
tonypauljohnson@yahoo.com |
Owner |
Cedar Rapids |
IA |
United States |
Anthony Johnson |
Olvin Lanza |
Signed |
460 |
2021-04-05 15:24 |
Anonymous (not verified) |
173.20.169.155 |
Tim Stiles |
Proprietorship |
726 Grant St PO box 217 Dexter Iowa 50070 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-04 |
Tim Stiles |
timcolleenstiles@gmail.com |
Dexter |
Dallas |
Iowa |
Karen Penton |
ERIC TIERNAN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Stiles |
timcolleenstiles@gmail.com |
Same Tim Stiles |
Dexter |
Dallas |
Iowa |
Karen Penton |
Eric Tiernan |
Signed |
572 |
2021-07-13 09:59 |
Anonymous (not verified) |
173.27.17.202 |
David Lochner |
Proprietorship |
866 40th ave Bettendorf Iowa 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-13 |
David Lochner |
jnagel@leafhome.com |
Dubuque |
Dubuque |
Iowa |
Jacob Nagel |
Shawn Cowell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Lochner |
jnagel@leafhome.com |
Self |
Dubuque |
Dubuque |
Iowa |
Jacob Nagel |
Shawn Cowell |
Signed |
684 |
2021-10-20 13:25 |
Anonymous (not verified) |
65.144.174.26 |
A and H Home Improvement |
Limited Liability Company |
600 NE 64th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-20 |
Ivan A. Abel |
aandhhomeimprovement@gmail.com |
Des Moines |
Polk |
Iowa |
Ken Krogman |
Bruce Baumgarn |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ivan A. Abel |
aandhhomeimprovement@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Ken Krogman |
Bruce Baumgarn |
Signed |
796 |
2021-12-15 07:58 |
Anonymous (not verified) |
173.22.84.26 |
LAMPE APPLIANCE SERVICE, Inc |
Proprietorship |
210 29TH ST NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-15 |
John Kenneth Lampe |
lampeappliance@gmail.com |
CEDAR RAPIDS |
Linn |
IA |
Douglas James Lampe |
Kenneth Roman Lampe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Douglas James Lampe |
lampeappliance@gmail.com |
Vice President |
CEDAR RAPIDS |
IA |
Linn |
Douglas James Lampe |
Kenneth Roman Lampe |
Signed |
955 |
2022-03-08 11:21 |
Anonymous (not verified) |
166.181.80.171 |
JB Roofing & Home Repair |
Limited Liability Company |
453 South Street Kalona, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-08 |
Jason Boller |
jbroofhr@gmail.com |
Kalona |
Washington |
IA |
Jodee Stransky |
Christian Swartzentruber |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christian Swartzentruber |
christian@fisherins.com |
Insurance Agent |
Kalona |
Washington |
IA |
Jodee Stransky |
Christian Swartzentruber |
Signed |
1067 |
2022-04-23 11:17 |
Anonymous (not verified) |
166.181.82.231 |
Black Squirrel Siding LLC. |
Limited Liability Partnership |
1512 north 1st ave 203s |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-23 |
Robby Bartosh |
zodzoey19@gmail.com |
Cedar Rapids |
IA |
United States |
Phoenix Bartosh |
Elijah Irish |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jeremiah Petsche |
Blacksquirrelsiding@gmail.com |
business partner |
coralville |
johnson |
iowa |
Phoenix Bartosh |
Elijah Irish |
Signed |
1866 |
2023-10-11 08:17 |
Anonymous (not verified) |
94.188.205.177 |
Wilson's Window Tinting |
Limited Liability Company |
385 South Stewart Street North Liberty, Iowa 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-07 |
Wilson Paiva |
wilsonswindowtinting@gmail.com |
North Liberty |
IA |
United States |
John W. Helscher |
Jose Omar Paz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wilson Paiva |
wilsonswindowtinting@gmail.com |
Owner |
North Liberty |
IA |
United States |
John Helscher |
Jose Omar Paz |
Signed |
1179 |
2022-07-05 12:21 |
Anonymous (not verified) |
173.18.233.175 |
Crossline Contracting LLC |
Limited Liability Company |
2009 Wilson Ave SW, Cedar Rapids, IA 52404 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Adam Anderson |
crosslinecontracting319@gmail.com |
Ryan, IA |
Deleware |
Iowa |
Branden Peters |
Todd Philpott |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Crossline Contracting LLC |
crosslinecontracting319@gmail.com |
Self |
Ryan Iowa |
Deleware |
Iowa |
Branden Peters |
Todd Philpott |
Signed |
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 |
1291 |
2022-09-02 13:24 |
Anonymous (not verified) |
173.20.146.6 |
Nicci Keck LLC |
Limited Liability Company |
1107 Pheasant Valley St, Iowa City, IA 52246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-02 |
Nicole Keck |
niccikeckllc@gmail.com |
Iowa City |
Iowa |
United States |
Evangeline Kadera |
Denise Kandel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicole Keck |
niccikeckllc@gmail.com |
Managing Member/Owner/President |
Iowa City |
Johnson |
Iowa |
Evangeline Kadera |
Denise Kandel |
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 |
1403 |
2023-01-03 15:23 |
Anonymous (not verified) |
173.20.50.85 |
Falcon Pride Properties, LLC |
Limited Liability Company |
1401 State Highway 57, Parkersburg, IA 50665 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-23 |
D. Jay Ellis |
cmins_re@mchsi.com |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
D. Jay Ellis |
cmins_re@mchsi.com |
Owner |
Parkersburg |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
28 |
2020-01-06 13:39 |
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 |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
GREELEY |
DELAWARE |
IOWA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NICOLAS MULLIS |
JAMES@CIOIA.COM |
OWNER |
GREELEY |
DELAWARE |
IA |
MERRI MOSER |
BRITTANY LANSING |
Signed |
2202 |
2024-05-06 11:36 |
Anonymous (not verified) |
94.188.207.224 |
Neil Wedeking |
Proprietorship |
408 Maple St, Nemaha, IA 50567 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-06 |
Neil Douglas Wedeking |
nandjwedeking@frontiernet.net |
Nemaha |
Sac |
Iowa |
Joseph McCollum |
Heather Husman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Wedeking |
nandjwedeking@frontiernet.net |
Self |
Nemaha |
Sac |
Iowa |
Joseph Paul McCollum |
Heather Lee Husman |
Signed |
1515 |
2023-03-13 15:04 |
Anonymous (not verified) |
94.188.207.226 |
Flint Hillman |
Proprietorship |
1019 E 17th St, APT 16, Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-13 |
Flint Hillman |
flinthillman@gmail.com |
Norwalk |
Warren |
Iowa |
Tina Robinson |
Paige Robinson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Flint Hillman |
flinthillman@gmail.com |
Self |
Norwalk |
Warren |
Iowa |
Tina Robinson |
Paige Robinson |
Signed |
140 |
2020-04-28 10:13 |
Anonymous (not verified) |
74.84.101.138 |
Lutheran Cemetery Association |
Proprietorship |
410 S. Mechanic Street Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-21 |
John D Noel |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John D Noel |
chelsea.whalen@upperiowains.com |
President |
Decorah |
Winneshiek |
IA |
Robin C Schultz |
Bobbi Jo Berg |
Signed |
1627 |
2023-05-08 13:43 |
Anonymous (not verified) |
94.188.205.169 |
CR TOTAL PLUMBING, INC. |
Limited Liability Company |
8190 Southern Hills Circle, 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. |
2023-05-05 |
Cory Ranson |
crpipes2@yahoo.com |
Dubuque |
Dubuque |
Iowa |
Randi Taylor |
Michelle Woodman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CR Total Plumbing, Inc |
crpipes2@yahoo.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Randi Taylor |
Michelle Woodman |
Signed |
252 |
2020-09-09 10:38 |
Anonymous (not verified) |
65.103.82.36 |
KNS |
Proprietorship |
PO Box 2632 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-04 |
Keith N Slyter |
KNSCONST@gmail.com |
Davenport |
Scott |
Iowa |
Eric Johnson |
Dawn Tague |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith N Slyter |
knsconst@gmail.com |
self |
Davenport |
Scott |
Ia |
Dawn Tague |
Eric Johnson |
Signed |
1739 |
2023-07-11 12:18 |
Anonymous (not verified) |
94.188.205.169 |
Innovators Construction LLC |
Limited Liability Company |
3230 180th St. Homestead, IA 52236. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-11 |
Juan Ramírez |
info@jmdrywallonline.com |
Homestead |
Iowa |
Iowa |
Itali Ramírez |
Guadalupe Ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Guadalupe Ramirez |
info@jmdrywallonline.com |
Business partner |
Homestead |
Iowa |
Iowa |
Itali Ramírez |
Juan M Ramírez |
Signed |
364 |
2021-01-14 13:46 |
Anonymous (not verified) |
173.31.147.225 |
JMAHER LLC |
Limited Liability Company |
907 4TH AVE SPENCER, IA 51301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-14 |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JUSTIN MAHER |
CCRIOWA@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
476 |
2021-04-13 19:23 |
Anonymous (not verified) |
173.31.147.225 |
COAST TO COAST MILLWRIGHT LLC |
Limited Liability Company |
2909 HWY 71 AND 9 SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-04-05 |
ADALBERTO CANTU |
JOEL@WALKERINSURANCEIA.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
ADALBERTO CANTU |
janiecantu433@outlook.com |
SELF-MEMBER |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
588 |
2021-07-27 19:59 |
Anonymous (not verified) |
75.162.226.22 |
Andres Martinez |
Limited Liability Company |
3903 SW 3rd St. Des Moines, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-27 |
Andres Martinez |
and.am12am@gmail.com |
Des Moines |
Polk |
Iowa |
Carla Martinez |
Librado Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Andres Martinez |
and.am12am@gmail.com |
Employer |
Des Moines |
Polk |
Iowa |
Carla Martinez |
Librado Martinez |
Signed |
700 |
2021-10-29 11:04 |
Anonymous (not verified) |
174.198.66.50 |
T&C Lawn Care LLC |
Limited Liability Partnership |
1827 Black Hawk St Waterloo IA 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-29 |
Cody R Woodley |
cody.woodley50@gmail.com |
Cedar Falls |
Blackhawk |
Iowa |
Tara R Woodley |
Sara Woodley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristi S. Demuth Agency, Inc. |
kdemuth@amfam.com |
Client |
Waverly |
Bremer |
Iowa |
Cody R Woodley |
Tyler M Croft |
Signed |
812 |
2021-12-22 17:31 |
Anonymous (not verified) |
166.181.85.89 |
Demmer Construction |
Proprietorship |
203 Michigan Ave Farley, IA 52046 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-22 |
Charles Demmer |
charliedemmer@gmail.com |
Farley |
Dubuque |
Ia |
Michele Demmer |
Jennifer White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Demmer |
charliedemmer@gmail.com |
Self |
Farley |
Dubuque |
Ia |
Michele Kay Demmer |
Jennifer Marie White |
Signed |
971 |
2022-03-14 17:59 |
Anonymous (not verified) |
207.32.37.48 |
Lynx Ag LLC |
Limited Liability Company |
510 H Ave, Churdan, IA 50050 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-14 |
Lance Glendenning |
lanceandabby@wccta.net |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Abby Glendenning |
accounting@lynxag.com |
Officer |
Churdan |
Greene |
Iowa |
Kim Kersey |
Shelly Brus |
Signed |
1770 |
2023-07-31 14:21 |
Anonymous (not verified) |
94.188.205.168 |
D & G Communications |
Proprietorship |
405 1st St N., PO Box 11 Farley, Iowa 52046 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-31 |
Dave Hirsch |
dngcomm@hotmail.com |
Farley |
Dubuque |
Iowa |
Zack Hirsch |
Nick Hirsch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dave Hirsch |
dngcomm@hotmail.com |
self |
Farley |
Dubuque |
Iowa |
Zach Hirsch |
Nick Hirsch |
Signed |
1083 |
2022-05-02 13:42 |
Anonymous (not verified) |
173.18.233.175 |
John Helm |
Proprietorship |
417 Pleasant Hill DR Atkins, IA 52206 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-02 |
John Helm |
johnhelmconstruction22@gmail.com |
Atkins |
Benton |
Iowa |
Brian Ashlock |
Trevor Vick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Helm |
johnhelmconstruction22@gmail.com |
Owner |
Atkins |
Benton |
IOWA |
Brian Ashlock |
Trevor Vick |
Signed |
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 |
1195 |
2022-07-08 13:24 |
Anonymous (not verified) |
174.198.67.66 |
Chapas Construction |
Limited Liability Company |
6424 Roseland Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-08 |
Polibio Raul Chapa Farez |
chapasconstructionllc@gmail.com |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Polibio Raul Chapa |
chapasconstructionllc@gmail.com |
President |
Urbandale |
IA |
IA |
Brenda Rivas |
Charlie Chapa |
Signed |
1994 |
2024-01-23 14:35 |
Anonymous (not verified) |
94.188.207.229 |
Josh Oswald |
Proprietorship |
505 Eisenhower Rd., Osceola, IA 50213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-23 |
Josh Oswald |
jjoswald47@gmail.com |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JOSHUA OSWALD |
jjoswald47@gmail.com |
Sole Proprietor |
Osceola |
Clarke |
Iowa |
Douglas Eugene Miller |
Elaine Lee |
Signed |
1307 |
2022-09-14 13:40 |
Anonymous (not verified) |
216.51.227.123 |
elite business ckeaning |
Proprietorship |
1350 kennel ct unit c2 north liberty IA 52317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-14 |
rogelio morales ortega |
info@elitebusinesscleaning.com |
iowa city |
johnson |
iowa |
cesar morales ortega |
alma rosa perez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
elite busibess cleaning |
info@elitebusinesscleaning.com |
president |
north liberty |
johnson |
iowa |
karina aguilar |
jessica lee |
Signed |
2106 |
2024-03-18 12:47 |
Anonymous (not verified) |
94.188.205.167 |
Scornos Altoona LLC |
Proprietorship |
2437 adventureland dr altoona iowaa 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Gary Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
Liana Fatino |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
wife |
des moines |
polk |
iowa |
Liana Fatino |
Lisa Vacco |
Signed |
1419 |
2023-01-12 09:27 |
Anonymous (not verified) |
71.34.173.44 |
Solid Solutions Caulking LLC. |
Limited Liability Company |
1011 N. Ankeny BLVD Po Box 216 Ankeny IA 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Jesse Guilford |
sscaulking@yahoo.com |
Ankeny |
Polk |
Iowa |
Jesse Guilford |
Jade Guilford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesse Guilford |
sscaulking@yahoo.com |
Self |
Ankeny |
Polk |
Iowa |
Jesse Guilford |
Jade Guilford |
Signed |
44 |
2020-01-28 12:55 |
Anonymous (not verified) |
173.24.181.211 |
AMANDA FIEDLER |
Proprietorship |
10 5TH AVE NW FOSTORIA, IA 51340 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-28 |
AMANDA FIEDLER |
JOEL@WALKERINSURANCEIA.COM |
FOSTORIA |
CLAY |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
AMANDA FIEDLER |
JOEL@WALKERINSURANCEIA.COM |
OWNER |
FOSTORIA |
CLAY |
IA |
JOSPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
2218 |
2024-05-09 16:20 |
Anonymous (not verified) |
94.188.205.167 |
Brenda Riseley |
Proprietorship |
2265 Copper Wynd Drive, Pleasant Hill Iowa 50327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-09 |
Brenda Riseley |
riseleybrenda@gmail.com |
Pleasant Hill |
IA |
United States |
Brenda Riseley |
Brenda Riseley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brenda Riseley |
riseleybrenda@gmail.com |
Self |
Pleasant Hill |
IA |
United States |
David Bottino |
Aubrey Stith |
Signed |
1531 |
2023-03-24 08:40 |
Anonymous (not verified) |
94.188.207.228 |
Schneiter Insurance and Financial Solutions |
Limited Liability Company |
900 E 3RD ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-01 |
Jackie Schneiter |
grlschneiter@gmail.com |
MONTICELLO |
IA |
United States |
Ronald Schneiter |
Reagan Schneiter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacqueline Schneiter |
jackie@we78ins.com |
owner |
ANAMOSA |
JONES |
IOWA |
RONALD SCHNEITER |
REAGAN SCHNEITER |
Signed |
156 |
2020-05-13 20:37 |
Anonymous (not verified) |
216.106.236.82 |
MR Electric LLC |
Limited Liability Company |
1853 230st Inwood, IA 51240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-13 |
Matthew Rozeboom |
matt.rozeboom@gmail.com |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Rozeboom |
matt.rozeboom@gmail.com |
Owner/President |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
1643 |
2023-05-12 07:56 |
Anonymous (not verified) |
94.188.205.169 |
Smooth Finish Drywall |
Proprietorship |
3111 115th Riverside, IA 52327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-12 |
Seth T Mize II |
stmize@hotmail.com |
Riverside |
Washington |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth T Mize II |
stmize@hotmail.com |
Self |
Riverside |
Washington |
Iowa |
Chris Hay |
Brad Bower |
Signed |
268 |
2020-09-22 09:21 |
Anonymous (not verified) |
174.217.16.178 |
Ayala Brothers Painting & Drywall |
Proprietorship |
25089 H Ave 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. |
2020-09-22 |
Edson Ayala Arizaga |
Ayalabrospainting@gmail.com |
Adel |
Dallas |
Iowa |
Abel Ayala |
Laura Orozco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edson Ayala Arizaga |
Edsonayala.12@gmail.com |
Owner |
Adel |
Dallas |
Iowa |
Abel Ayala |
Laura Orozco |
Signed |
1755 |
2023-07-19 22:43 |
Anonymous (not verified) |
94.188.207.230 |
Ellison building and repair |
Limited Liability Company |
2722 645th ave moravia iowa 52571 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-19 |
Keeton Ellison |
sammyllsn@yahoo.com |
Moravia |
Appanoose |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sammy Ellison |
sammyllsn@yahoo.com |
Mom |
Moravia |
Monroe |
Iowa |
Cory Ellison |
Sammy Ellison |
Signed |
380 |
2021-02-01 15:04 |
Anonymous (not verified) |
192.30.185.142 |
Chelos Framing Crew |
Proprietorship |
501 Colon Street, Sioux City, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-01 |
Marcelo Lopez |
chelosframingcrew@icloud.com |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Virginia Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcelo Lopez |
chelosframingcrew@icloud.com |
Owner |
Sioux City |
Woodbury |
IA |
Katie Jenks |
Virginia Anderson |
Signed |
492 |
2021-04-22 08:33 |
Anonymous (not verified) |
66.188.136.150 |
Adrian Hackney |
Proprietorship |
1513 7th St. Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-20 |
Adrian Hackney |
kschumacher@tricorinsurance.com |
Boone |
Boone |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adrian Hackney |
kschumacher@tricorinsurance.com |
Same |
Boone |
Boone |
IA |
Shuree Behr |
Mitch Kemp |
Signed |
604 |
2021-08-14 11:18 |
Anonymous (not verified) |
69.54.119.134 |
Robert Curry |
Limited Liability Company |
10759 S 96th Ave W Prairie City IA 50228 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-14 |
Bob Curry |
Gardengal4205@gmail.com |
Prairie City |
IA |
United States |
Megan Irwin |
Rob Irwin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Curry |
Gardengal4205@gmail.com |
Self |
Prairie City |
IA |
United States |
Megan Irwin |
Rob Irwin |
Signed |
716 |
2021-11-05 13:22 |
Anonymous (not verified) |
209.252.172.87 |
Rick Clifford Clifford Custom Tile & Flooring |
Proprietorship |
1563 Palmer Ct NE, Solon, IA 52333 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-24 |
Rick Clifford |
cliffordcustomtile@gmail.com |
Solon |
Johnson |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rick Clifford Clifford Custom Tile & Flooring |
cliffordcustomtile@gmail.com |
Self Employed |
Solon |
Johnson |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
828 |
2022-01-11 10:34 |
Anonymous (not verified) |
74.215.151.63 |
Marr Arnold Planning |
Limited Liability Company |
1328 California Ave. Ames Iowa 50014 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-11 |
Sarah Arnold |
sarahkarnold@gmail.com |
Cincinnati |
Hamilton |
Ohio |
April Humphreys |
Amy Burns |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sarah Arnold |
sarah@marrarnoldplanning.com |
Self |
Cincinnati |
Hamilton |
Ohio |
Amy Burns |
April Humphreys |
Signed |
987 |
2022-03-20 10:53 |
Anonymous (not verified) |
75.162.173.186 |
John Greenman Painting |
Proprietorship |
111 Village Drive West Des Moines Ia,50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-20 |
john greenman |
greenmanj55@gmail.com |
west des moines |
iowa |
iowa |
Angela Kay Olsem |
Peggy Ann Greenman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John William Greenman |
greenmanj55@gmail.com |
owner |
west des moines |
iowa |
iowa |
Angela Kay Olsem |
Peggy Ann Greenman |
Signed |
1786 |
2023-08-07 05:08 |
Anonymous (not verified) |
94.188.205.169 |
Ph Construction Limited Liability Company |
Limited Liability Company |
2643 Beaver Ave Suite 105 Des Moines Iowa 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-07 |
Patricia Ann Hook |
patricia.diverseconstruction@gmail.com |
Des Moines |
United States |
United States |
Allen W Butts |
Kate Ridge |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Patricia Ann Hook |
patricia.diverseconstruction@gmail.com |
Self - Owner |
Des Moines |
United States |
Iowa |
Allen W Butts |
Kate Ridge |
Signed |
1099 |
2022-05-13 12:17 |
Anonymous (not verified) |
75.162.66.90 |
EMPIRE CONTRACTORS, LLC |
Limited Liability Company |
8415 FRANKLIN AVE APT 18 CLIVE, IOWA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-13 |
RENE ALEXANDER VELASCO |
velasco.alexander@yahoo.com |
Des Moines |
USA |
Iowa |
Yolanda Mendoza |
Liliana Sanchez Gutierrez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RENE ALEXANDER VELASCO |
velasco.alexander@yahoo.com |
OWNER |
DES MOINES |
USA |
IOWA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
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 |
1211 |
2022-07-18 14:10 |
Anonymous (not verified) |
172.58.85.43 |
Palomeque Gutter LLC |
Limited Liability Company |
2004 se 24th st Grimes IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-18 |
Philips Palomeque |
ecuaphilips94@gmail.com |
Des Moines IA |
USA |
Iowa |
Philips Peter Palomeque Vallejo |
Philips Palomeque |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Philips Palomeque |
ecuaphilips94@gmail.com |
Owner |
Des Moines |
USA |
Iowa |
Philips Peter Palomeque Vallejo |
Erika Zapata |
Signed |
2010 |
2024-01-30 11:46 |
Anonymous (not verified) |
94.188.207.230 |
Kevin & Jlynn Jones |
Proprietorship |
1500 15th St. Milford Ia 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-30 |
Jlynn Jones |
KEVINMJONES81@GMAIL.COM |
Milford |
Dickinson |
Iowa |
Tami Klein |
Joseph Loring |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin & Jlynn Jones |
KEVINMJONES81@GMAIL.COM |
Self |
Milford |
Dickinson |
Iowa |
Tami Klein |
Joseph Loring |
Signed |
1323 |
2022-09-28 22:45 |
Anonymous (not verified) |
74.51.212.66 |
OUTDOOR MODERN CONCEPTS LLC |
Limited Liability Company |
2520 RIVER MEADOWS DR., DES MOINES, IA, 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-28 |
CHRISTIAN RUBIO |
RUBIOCH39@GMAIL.COM |
DES MOINES |
POLK |
IOWA |
AMANDA DUPRE |
DARCI CLARK |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JENNIFER B. CHAVEZ-RIVERA |
JENNIFER.CHAVEZ-RIVERA@BROWNWINICK.COM |
ATTORNEY |
DES MOINES |
POLK |
IOWA |
AMANDA DUPRE |
DARCI CLARK |
Signed |
2122 |
2024-03-28 10:15 |
Anonymous (not verified) |
94.188.205.169 |
Stone Villalobos LLC |
Limited Liability Company |
4231 Morton Ave Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-28 |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josue Villalobos |
villalobosjosue2016@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Edgar Palomares |
Fabiola Palomares Recendiz |
Signed |
1435 |
2023-01-31 14:33 |
Anonymous (not verified) |
174.215.242.112 |
Premier builders |
Proprietorship |
1821 East Ridgeway |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-31 |
Edward Koch |
etkdbq@aol.com |
Waterloo |
IA |
United States |
Glenda mclarty |
Coen Koch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edward Koch |
etkdbq@aol.com |
Owner |
Waterloo |
IA |
United States |
Glenda Mclarty |
Coen Koch |
Signed |
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 |
1547 |
2023-03-30 08:45 |
Anonymous (not verified) |
94.188.207.223 |
Palomeque Gutter LLC |
Limited Liability Company |
2004 SE 24TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-30 |
Philips Palomeque |
ecuaphilips94@gmail.com |
Grimes |
USA |
IA |
Philips Palomeque |
Philips Palomeque |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Philips Palomeque |
ecuaphilips94@gmail.com |
My self |
Grimes |
USA |
Ia |
Philips Palomeque |
Philips Palomeque |
Signed |
172 |
2020-06-02 15:56 |
Anonymous (not verified) |
66.188.136.150 |
David Bull |
Proprietorship |
221 N Aarlocker St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-02 |
David Bull |
kschumacher@tricorinsurance.com |
Mount Hope |
Grant |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Bull |
kschumacher@tricorinsurance.com |
Same |
Mount Hope |
Grant |
WI |
Russell Masartis |
Nancy Wortley |
Signed |
1659 |
2023-05-23 13:39 |
Anonymous (not verified) |
94.188.205.168 |
Rosendo Mora |
Proprietorship |
222 E Webster Street, Goldfield IA 50542 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
Rosendo Mora |
office.seamlesspros@icloud.com |
Goldfield |
Wright |
Iowa |
Anthony Buck |
Troy Knutson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rosendo Mora |
office.seamlesspros@icloud.com |
Self |
Goldfield |
Wright |
Iowa |
Anthony Buck |
Troy Knutson |
Signed |
284 |
2020-10-21 12:52 |
Anonymous (not verified) |
207.177.50.27 |
Luke Croghan |
Proprietorship |
2404 2200th street ,Manilla Ia. 51454 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-21 |
luke F Croghan |
croghanluke@gmail.com |
manilla |
Shelby |
Iowa |
Amy Hansen |
Todd Stadlander |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
luke F Croghan |
croghanluke@gmail.com |
Owner |
manilla |
Shelby |
Iowa |
Amy Hansen |
Todd Stadlander |
Signed |
396 |
2021-02-12 15:05 |
Anonymous (not verified) |
173.28.7.235 |
Brad Neff |
Limited Liability Company |
5431 gear st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-12 |
Wesley Detman |
wesdet@gmail.com |
Des moines |
Iowa |
United States |
Leah Laxton |
Wesley Detman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
All pro painting, LLC |
Brad@allpropaintingdsm.com |
Self |
Prole |
Warren |
Iowa |
Wesley Detman |
Leah Laxton |
Signed |
508 |
2021-05-10 11:56 |
Anonymous (not verified) |
172.58.83.106 |
Aldo Monroy |
Limited Liability Company |
201 Ne 44th St , Apt 111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-10 |
Aldo Monroy |
Aldogmonroy@gmail.com |
Ankeny |
Polk |
IOWA |
Aldo Monroy |
Elizabeth lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Aldo Monroy |
Aldogmonroy@gmail.com |
Owner |
Ankeny |
Polk |
IOWA |
Aldo g monroy reyes |
Elizabeth tavarez lopez |
Signed |
620 |
2021-08-26 16:26 |
Anonymous (not verified) |
75.162.146.246 |
Daniel Meza Reyes |
Proprietorship |
1640 E Army Post RD Des Moines IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-23 |
Daniel Meza Reyes |
danielmr9247@gmail.com |
Des Moines |
polk |
IA |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Meza Reyes |
danielmr9247@gmail.com |
self |
Des Moines |
polk |
IA |
Yolanda Mendoza |
Liliana Sanchez |
Signed |
732 |
2021-11-09 15:25 |
Anonymous (not verified) |
50.83.182.182 |
United Trades Group LLC |
Limited Liability Company |
4813 Candlewick Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-09 |
Ryan Drabek |
ryand@unitedtradesgroup.org |
Des Moines |
Polk |
Iowa |
Dustin Kohler |
Trevor Spidle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tory Webb |
toryw@unitedtradesgroup.org |
Owner, Management |
Norwalk |
Warren |
Iowa |
Trevor Spidle |
Dustin Kohler |
Signed |
844 |
2022-01-20 08:55 |
Anonymous (not verified) |
172.58.87.106 |
Barkley Coatings |
Limited Liability Company |
305 E 20th St S |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-20 |
Heath |
barkleyheath@yahoo.com |
Newton |
United States |
Iowa |
Matthew Blunk |
Hailey Scott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heath Barkley |
barkleyheath@yahoo.com |
Owner |
Newton |
IA |
United States |
Matthew Blunk |
Hailey Scott |
Signed |
891 |
2022-02-03 15:25 |
Anonymous (not verified) |
173.23.180.117 |
Roy Dawson |
Proprietorship |
2602 Green Creek, Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-03 |
Roy Dawson |
roydawson19@gmail.com |
Cedar Falls |
Black Hawk County |
Iowa |
Nickole Pry |
Christine Willis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Roy Dawson |
roydawson19@gmail.com |
Same person |
Cedar Falls |
Black Hawk |
Iowa |
Nickole Pry |
Christine Willis |
Signed |
1003 |
2022-03-23 13:06 |
Anonymous (not verified) |
24.149.3.190 |
Thomas Wedmore |
Proprietorship |
200 State St, Ste 202G, Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-23 |
Thomas Wedmore |
twedmore@phillipsstafford.com |
Cedar Falls |
IA |
United States |
Bradley Phillips |
Joshua Stafford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Wedmore |
twedmore@phillipsstafford.com |
Self |
Reinbeck |
Grundy |
IA |
Bradley Phillips |
Joshua Stafford |
Signed |
1802 |
2023-08-15 15:23 |
Anonymous (not verified) |
94.188.205.174 |
NORTH STARS, LLC |
Limited Liability Company |
4374 STATE ST STE 2 BETTENDORF, IA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-15 |
JOSE A DURAN MORALES |
northstarsllcmn@gmail.com |
BETTENDORF |
USA |
IOWA |
ARMANDO DURAN |
LILIANA SANCHEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
NORTH STARS, LLC |
northstarsllcmn@gmail.com |
BUSINESS OWNER |
BETTENDORF |
USA |
IOWA |
LILIANA SANCHEZ |
ARMANDO DURAN |
Signed |
1115 |
2022-05-17 19:36 |
Anonymous (not verified) |
173.23.50.204 |
Delgado Electrical Services |
Limited Liability Company |
1210 Creston 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. |
2022-05-17 |
Cesar Delgado |
delgado.electrical@gmail.com |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Delgado |
cesar.delgado31@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Mike Willet |
Alex Segovia |
Signed |
1914 |
2023-11-20 16:05 |
Anonymous (not verified) |
94.188.207.227 |
Dark Horse Transport LLC |
Limited Liability Company |
301 Lincoln St, Brayton, IA 50042 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-20 |
James William Meese |
bethany.dhtllc@gmail.com |
Brayton |
Audubon |
Iowa |
Hayley Meese-Cherry |
Wyatt Jessen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Wiliam Meese |
bethany.dhtllc@gmail.com |
Owner |
Brayton |
Audubon |
Iowa |
Hayley Meese-Cherry |
Wyatt Jessen |
Signed |
1227 |
2022-07-26 09:20 |
Anonymous (not verified) |
173.27.17.3 |
LeafFilter North LLC |
Proprietorship |
866 40th Ave bettendorf IA 52722 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-26 |
Craig Stang |
stangcraig@gmail.com |
Moline |
Rock island |
IL |
Cody Dunbar |
Tiffani Branham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LeafFilter North LLC |
cdunbar@leaffilter.com |
Install manager |
Bettendorf |
Iowa |
United States |
Cody dunbar |
Tiffani Branham |
Signed |
2026 |
2024-02-07 08:32 |
Anonymous (not verified) |
94.188.205.169 |
Strong Fencing & Decking LLC |
Limited Liability Company |
343 59th Street Des Moines Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-07 |
Jacob James Strong |
strongfencingdecking@gmail.com |
Des Moines |
Polk |
Iowa |
Paige Crowley |
Jacob Waugh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob Strong |
strongfencingdecking@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Paige Crowley |
Jacob Waugh |
Signed |
1339 |
2022-10-18 14:14 |
Anonymous (not verified) |
97.125.41.64 |
Juan Buenrostro |
Proprietorship |
2122 E 39th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-18 |
Juan Buenrostro |
juanjosebuenrostro@gmail.com |
Des Moines |
Polk |
IA |
Juan Buenrostro |
Kelly gonzalez buenrostro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan nisiewicz |
jnisiewicz@leafhome.com |
Regional recruiter |
Kansas City |
Clay |
Missouri |
Jordan nisiewicz |
Jordan loyd |
Signed |
2138 |
2024-04-05 12:30 |
Anonymous (not verified) |
94.188.205.167 |
Joseph L Neighbors dba J L N Trucking |
Proprietorship |
5466 18th Ave Mount Auburn IA 52313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-05 |
Joseph L Neighbors |
robynne@cmbrown.net |
Mount Auburn |
Benton |
Iowa |
Sarah Svehla |
Angela Vangennip |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robynne Dawn Duvall |
robynne@cmbrown.net |
insurance agent |
Perryville |
Missouri |
Missouri |
Sarah Svehla |
Angela Vangennip |
Signed |
1451 |
2023-02-13 13:27 |
Anonymous (not verified) |
94.188.205.168 |
Better Built Floors, LLC |
Limited Liability Company |
950 Spruce street Waukee, IA, 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-13 |
Bodhi Cox |
betterbuiltfloors@gmail.com |
waukee |
dallas |
iowa |
Bodhi Cox |
Daniel Cox |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bodhi Cox |
betterbuiltfloors@gmail.com |
i am thge owner/operator |
waukee |
dallas |
iowa |
Bodhi Cox |
Daniel Cox |
Signed |
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 |
1563 |
2023-04-11 08:49 |
Anonymous (not verified) |
94.188.205.168 |
Ibrahim Sehic |
Proprietorship |
4052 Lafayette Rd, Evansdale, IA 50707 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-11 |
Ibrahim Sehic |
bacosidig@gmail.com |
Evansdale, IA |
Black Hawk County |
Iowa |
Jordan Nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Warren Crow |
Signed |
188 |
2020-06-15 11:55 |
Anonymous (not verified) |
67.60.42.173 |
SANDS CONSTRUCTION LLC |
Limited Liability Company |
3812 Sioux River Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-06-15 |
Ryan Sands |
rn_sands@hotmail.com |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Ryan Sands |
rn_sands@hotmail.com |
self/ Owner/ Operator |
Sioux City |
IA |
IA |
Nicole Sands |
Reese Sands |
Signed |
1675 |
2023-06-02 09:37 |
Anonymous (not verified) |
94.188.207.228 |
Kacena Family Tree Farm Inc |
Partnership |
2510 55th St., Vinton, IA 52349 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-01 |
Kevin Kacena |
kacenafarms.alyce@gmail.com |
Vinton |
Benton |
Iowa |
Ashlyn J. Christianson |
Angie McFarland |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alyce Lynch |
ashlyn@3riversins.net |
25% Owner - President |
Vinton |
Benton |
Iowa |
Ashlyn J. Christianson |
Angie McFarland |
Signed |
300 |
2020-10-30 10:51 |
Anonymous (not verified) |
216.51.132.207 |
Joe Kann & Luke Kann |
Partnership |
32256 Leaf Rd Guttenberg IA 52052 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-28 |
Joe Kann |
kannbros1895@gmail.com |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joe Kann |
kannbros1895@gmail.com |
owner |
Guttenberg |
Clayton |
Iowa |
Jerry J Rochford |
Nicole L Parker |
Signed |
412 |
2021-02-23 14:23 |
Anonymous (not verified) |
205.185.135.176 |
Jeffrey Meyer |
Proprietorship |
118 1st St SE New Albin IA 52160 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-23 |
Jeffrey Meyer |
meyertimberservices@gmail.com |
New Albin |
Allamakee |
Iowa |
Michael Klug |
Kayla Snitker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Klug |
mike@aibme.com |
Insurance Agent |
Caledonia |
Houston |
Minnesota |
Jeffrey Meyer |
Kayla Snitker |
Signed |
524 |
2021-05-17 22:41 |
Anonymous (not verified) |
166.181.84.162 |
Laven Construction LLC |
Limited Liability Company |
4935 NE 78th Ave Bondurant, Iowa 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-17 |
MacKale Laven |
maclaven@gmail.com |
Bondurant |
Polk |
Iowa |
John Smith |
Cameron Thede |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MacKale Laven |
maclaven@gmail.com |
Owner |
Bondurant |
Polk |
Iowa |
Cameron Thede |
John Smith |
Signed |
636 |
2021-09-10 14:56 |
Anonymous (not verified) |
173.19.179.111 |
SHANNON SUNDINE |
Proprietorship |
513 16TH ST SPIRIT LAKE IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-10 |
SHANNON SUNDINE |
SPSUNDINE@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNG WIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SHANNON SUNDINE |
SPSUNDINE@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKINSON |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
748 |
2021-11-15 13:01 |
Anonymous (not verified) |
174.243.83.168 |
NC contracting |
Limited Liability Company |
2212 Oakwood Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-15 |
Nicholas Cheney |
444nicholas@gmail.com |
Ames |
Iowa |
Iowa |
Cassie Cheney |
Shawn Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Cheney |
444nicholas@gmail.com |
Self |
Ames |
Story |
Iowa |
Cassie Cheney |
Shawn Hay |
Signed |
860 |
2022-01-27 11:31 |
Anonymous (not verified) |
69.63.16.2 |
Dreams 2 Reality Construction LLC |
Limited Liability Company |
17615 Meredith Dr, Waukee, IA 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-26 |
Rob Rubsam |
rob@dreams2reality.us |
Waukee |
Dallas |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rob Rubsam |
rob@dreams2reality.us |
Member |
Waukee |
Dallas |
Iowa |
Kyle Stahle |
Dyan Kriener |
Signed |
907 |
2022-02-09 08:59 |
Anonymous (not verified) |
173.28.0.37 |
Rusty K5 LLC |
Limited Liability Company |
804 SW Cherry St Ankeny, IA 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-09 |
Kristy Briles |
kristyabriles@gmail.com |
Des Moines |
Polk |
IA |
Stephanie Seymour |
Sue Briles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristy Briles |
kristyabriles@gmail.com |
Owner |
Des moines |
Polk |
IA |
50313 |
Sue Briles |
Signed |
1019 |
2022-03-29 16:42 |
Anonymous (not verified) |
104.201.100.158 |
Nayeri Group LLC |
Limited Liability Company |
412 SE 17th Court, Grimes, Iowa 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Sima Dehghan Nayeri |
nayeri.sima@gmail.com |
Grimes |
Polk |
Iowa |
Jacob Willis |
Lucas Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sima Nayeri |
nayeri.sima@gmail.com |
Self |
Grimes |
Polk |
Iowa |
Jacob Willis |
Lucas Peterson |
Signed |
2039 |
2024-02-08 09:25 |
Anonymous (not verified) |
94.188.207.229 |
Home Re Construction, LLC |
Limited Liability Company |
5285 NE Mitchell Drive, Mitchellville, IA 50169 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Francisco Miguel Palomares Velasco |
homereconstruction@hotmail.com |
Mitchellville |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Francisco Miguel Palomares Velasco |
homereconstruction@hotmail.com |
Self |
Mithcellville |
Polk |
Iowa |
Fabiola Palomares Recendiz |
Nathan Miller |
Signed |
1352 |
2022-10-31 19:35 |
Anonymous (not verified) |
173.17.8.56 |
Hutch's Parking Lot Sweeping INC |
Limited Liability Company |
5235 JENNIFER DR |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-31 |
Bill HUTCHINSON |
btnwhutch@aol.com |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
NIC HUTCHINSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bill HUTCHINSON |
btnwhutch@aol.com |
SELF |
PLEASANT HILL |
Iowa |
United States |
TRACY HUTCHINSON |
NIC HUTCHINSON |
Signed |
2151 |
2024-04-15 14:42 |
Anonymous (not verified) |
94.188.207.227 |
Jose Acuna |
Proprietorship |
1015 East Main Street, Belmond, IA 50421, US |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-15 |
Jose Acuna |
Joseacuna@gmail.com |
Belmond, IA |
Wright |
Iowa |
Jordan Loyd |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Johnson |
Missouri |
Jordan Loyd |
Cody Dunbar |
Signed |
1464 |
2023-02-17 15:05 |
Anonymous (not verified) |
94.188.205.166 |
Jordan Walkup |
Proprietorship |
5751 NE 22nd St Des Moines IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Jordan Walkup |
jordanw@bigroofing515.com |
Windsor Heights |
Polk |
IA |
Sarah Walkup |
Steve Bieghler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Walkup |
jordanw@bigroofing515.com |
Self |
Windsor Heights |
Polk |
IA |
Sarah Walkup |
Steve Bieghler |
Signed |
89 |
2020-03-13 12:41 |
Anonymous (not verified) |
216.96.113.16 |
B’s Sweet Treats |
Proprietorship |
123 E Marion St. Sigourney IA 52591 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-13 |
Brandi Wehr |
brndwehr54@hotmail.com |
Sigourney |
Keokuk |
IA |
Brandi |
Brandi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandi Wehr |
brndwehr54@hotmail.com |
Same |
Sigourney |
Keokuk |
IA |
Brandi |
Brandi |
Signed |
1576 |
2023-04-17 08:32 |
Anonymous (not verified) |
94.188.205.167 |
Reece Wilson |
Limited Liability Company |
1431 Starbeck Circle |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-14 |
Reece J Wilson |
rjwilson030@gmail.com |
Cedar Falls |
Blackhawk |
Iowa |
Kendall Cotant |
Darryl Mason |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Richter |
jrichter@beecherlaw.com |
Business |
Waterloo |
Blackhawk |
Iowa |
Kendall Cotant |
Jared Hottle |
Signed |
201 |
2020-07-09 11:07 |
Anonymous (not verified) |
167.142.98.40 |
Brock Chisum |
Proprietorship |
369 Wise Rd., Decatur, TX76234 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-09 |
Brock Chisum |
bchisum@hotmail.com |
Decatur, TX |
Wise |
Texas |
Lakota Larson |
Ryan Stott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brock Chisum |
bchisum@hotmail.com |
Self |
Decatur |
Wise |
Texas |
Lakota Larson |
Ryan Stott |
Signed |
1688 |
2023-06-13 09:29 |
Anonymous (not verified) |
94.188.207.228 |
Ron Burbach |
Proprietorship |
7760 commerce park Dubuque Iowa 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-13 |
Ronald V Burbach |
allgreenron@msn.com |
Dubuque |
Dubuqie |
Iowa |
Mia Burnach |
Jerry david |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ronald V Burbach |
allgreenron@man.com |
Same |
Dubuque |
Dubuque |
Iowa |
Mia F Burbach |
Jerry David |
Signed |
313 |
2020-11-11 20:35 |
Anonymous (not verified) |
174.198.78.148 |
Wilson Snow Maintenance |
Proprietorship |
3518 183rd Avenue, Carlisle, Iowa 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-11 |
Bruce E. Wilson |
bewilson83@gmail.com |
Carlisle |
Warren |
Iowa |
Kristen Wilson |
Garett Wilson |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Bruce Wilson |
bewilson83@gmail.com |
self |
Carlisle |
Warren |
Iowa |
Kristen Wilson |
Garett Wilson |
Signed |
425 |
2021-03-05 16:03 |
Anonymous (not verified) |
65.103.82.36 |
Ryan Richard |
Proprietorship |
1425 W 34th Street, Davenport IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-15 |
Ryan Richard |
RRichard@gmail.com |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Richard |
RRichard@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
537 |
2021-06-07 15:25 |
Anonymous (not verified) |
66.188.136.150 |
Casey Young |
Proprietorship |
10731 State Highway 118 Turrell, AR 72384 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-03 |
Casey Young |
kschumacher@tricorinsurance.com |
Turrell |
Crittenden |
AR |
Mitch Kemp |
Shuree Behr |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Casey Young |
kschumacher@tricorinsurance.com |
Same |
Turrell |
Crittenden |
AR |
Mitch Kemp |
Shuree Behr |
Signed |
649 |
2021-09-21 13:15 |
Anonymous (not verified) |
208.126.118.26 |
Wade Smith DBA WADA Farms |
Proprietorship |
2428 270th st, Grand Mound, IA 52751 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-09-21 |
Wade Smith |
wade.smith1110@gmail.com |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wade Smith |
wade.smith1110@gmail.com |
self |
Grand Mound |
Clinton |
Iowa |
Megan Fuglsang |
Jenny Gordon |
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 |
873 |
2022-01-30 18:57 |
Anonymous (not verified) |
75.162.11.91 |
Iowa Carpentry Construction |
Limited Liability Company |
3000 University Ave West Des Moines,IA 50266 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-01 |
Martha Marca |
Iowacarpentryconstruction@gmail.com |
Urbandale |
Polk |
Iowa |
Martha Marca |
Carlos Velazquez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Emily Segura |
iowacarpentryconstrucion@gmail.com |
Worker |
West Des Moines |
Polk |
Iowa |
Martha Marca |
Carlos Velazquez |
Signed |
920 |
2022-02-17 10:15 |
Anonymous (not verified) |
208.81.192.69 |
Wapsie Valley Construction, LLC |
Limited Liability Company |
1154 Dennison Avenue, Fairbank, IA 50629 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Merle B. Miller |
accounting@robertseddy.com |
Fairbank |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Merle B. Miller |
accounting@robertseddy.com |
Same person |
Fairbank |
Buchanan |
Iowa |
Brian C. Eddy |
Samantha J. Stelter |
Signed |
1032 |
2022-04-05 09:21 |
Anonymous (not verified) |
75.89.4.2 |
KG land works |
Limited Liability Company |
812 cr 2401 barnsdall Oklahoma 74002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
Wyatt ray slone |
wyattslone177@gmail.com |
Barnsdalll |
Osage |
OK |
Dalton Gardner |
Colton Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Colton Kelley |
kglandworks@gmail.com |
Day helper |
Barnsdalll |
Osage |
OK |
Colton Kelley |
Dalton Gardner |
Signed |
1831 |
2023-09-08 11:50 |
Anonymous (not verified) |
94.188.207.223 |
GFORCE |
Limited Liability Company |
529 Anderson Street Jewell IA 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-06 |
Colten Abram Griffin |
G6@q.com |
Ames |
Story |
Iowa |
Scott Andrew Griffin |
Hunter Austin Griffin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Hunter Austin Griffin |
G6@q.com |
Partner |
Urbandale |
Polk |
Iowa |
Scott Andrew Griffin |
Colten Abram Griffin |
Signed |
1144 |
2022-06-06 15:51 |
Anonymous (not verified) |
63.152.93.184 |
Mark Moser |
Limited Liability Company |
904 W 4th St., Waterloo Iowa 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-02 |
Mark Moser |
mpmmoser@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Timothy Combs |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Moser |
mpmmoser@gmail.com |
none |
Waterloo |
Black Hawk |
Iowa |
Timothy Combs |
Teresa Tjaden |
Signed |
1943 |
2023-12-06 16:34 |
Anonymous (not verified) |
94.188.207.230 |
Your Neighbors Pressure Washing LLC |
Limited Liability Company |
2059 Lyon St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Myself |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
1256 |
2022-08-15 13:22 |
Anonymous (not verified) |
173.29.47.222 |
Premiere Plastering & Drywall, Inc. |
Proprietorship |
2331 W. 63rd St., Davenport, IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-08-08 |
Richard Miller |
rmiller0574@gmail.com |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Premiere Plastering & Drywall, Inc. |
premiere_pd_llc@yahoo.com |
Subcontractor |
Davenport |
Iowa |
United States |
Jamie Wardlow |
Kandra Blumenshein |
Signed |
2055 |
2024-02-23 14:54 |
Anonymous (not verified) |
94.188.207.224 |
Neil Vonnahme |
Proprietorship |
13628 220th St., Arcadia, Iowa, 51430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-20 |
Neil Vonnahme |
neilvonnahme@gmail.com |
Arcadia |
Carroll |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Neil Vonnahme |
neilvonnahme@gmail.com |
Self |
Arcadia |
Carroll |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
1368 |
2022-11-11 11:58 |
Anonymous (not verified) |
173.29.231.17 |
Marcelino Gutierrez |
Proprietorship |
1705 Des Moines Street, Des Moines, Iowa 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-11 |
Marcelino Gutierrez |
lifestylefloors20@gmail.com |
Des Moines |
Polk |
Iowa |
Jerry Downing |
Ashley Temple |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcelino Gutierrez |
Lifestylefloors20@gmail.com |
owner |
Des Moines |
Polk |
Iowa |
Jerry Downing |
Ashley Downing |
Signed |
2167 |
2024-04-21 22:01 |
Anonymous (not verified) |
94.188.205.177 |
The Duerson Corportaion |
Proprietorship |
601 1st Ave N, Altoona, IA 50009 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-21 |
Nicholas John Myers |
myersnicholasj@gmail.com |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas John Myers |
myersnicholasj@gmail.com |
Owner |
Norwalk |
IA |
United States |
Theresa Myers |
Bradyn Smith |
Signed |
1480 |
2023-02-24 08:54 |
Anonymous (not verified) |
94.188.205.176 |
Shear Texture |
Limited Liability Company |
2000 Wiley Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-24 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
105 |
2020-03-27 12:15 |
Anonymous (not verified) |
174.219.134.4 |
Elijah Willier |
Proprietorship |
805 SE 15th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-27 |
Elijah Willier |
e.willier42798@gmail.com |
Grimes |
Polk |
IA |
Isaac Willier |
Isaiah Willier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Elijah Willier |
e.willier42798@gmail.com |
Self/ sole proprietor |
Grimes |
Polk |
IA |
Isaac Willier |
Isaiah Willier |
Signed |
1592 |
2023-04-22 22:46 |
Anonymous (not verified) |
94.188.207.223 |
D&L painting LLC |
Limited Liability Company |
3109 E13th st des moines IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-22 |
Lenin Borjas Varela |
leninborjas92@gmail.com |
Des moines |
Iowa |
Iowa |
Berenice Silva |
Gustado Valdes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lenin Borjas Varela |
leninborjas92@gmail.com |
Dueño |
Clive |
Iowa |
Iowa |
Berenice silva |
Gustado Valdes |
Signed |
217 |
2020-07-27 14:56 |
Anonymous (not verified) |
72.2.163.232 |
Calvin Kroger |
Proprietorship |
48232 292nd St. Hudson, SD 57034 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-27 |
Calvin Kroger |
calvinkroger@gmail.com |
Hudson |
Lincoln |
South Dakota |
Robin Anderson |
Adam Anderson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Calvin Kroger |
calvinkroger@gmail.com |
proprietor |
Hudson |
Lincoln |
South Dakota |
Robin Anderson |
Adam Anderson |
Signed |
1704 |
2023-06-23 09:00 |
Anonymous (not verified) |
94.188.205.166 |
THen & Kramer Construcion, Inc. |
Partnership |
P.O. Box 283 - Epworth, IA 52045 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
Dakota Kramer |
dparsons@english-insurance.com |
Epworth, |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derrick Parsons |
dparsons@english-insurance.com |
self |
Dyersville |
Dubuque |
IA |
Derrick Parsons |
Joyce Heims |
Signed |
329 |
2020-12-01 10:02 |
Anonymous (not verified) |
74.84.125.43 |
BRAINARD ROOFING & CONSTRUCTION COMPANY |
Limited Liability Company |
4 South Ross St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-01 |
Cody Brainard |
brainardrcc2020@gmail.com |
Farmersburg |
Clayton |
United States |
Dave Moellers |
Jordan Cannon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cody Brainard |
brainardrcc2020@gmail.com |
I am the authorized agent & employer |
Farmersburg |
IA |
United States |
Dave Moellers |
Jordan Cannon |
Signed |
441 |
2021-03-18 16:20 |
Anonymous (not verified) |
173.25.156.33 |
CYALCO AVIATION LLC |
Limited Liability Company |
3710 W. MILWAUKEE ST, SPENCER, IA 51301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-03-18 |
WILLIAM A. VAN LENT |
bvl@veridian.net |
WEST DES MOINES |
POLK |
IOWA |
ERIN MONFORT NELSON |
COLE M. VAN LENT |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
WILLIAM A. VAN LENT |
bvl@veridian.net |
SAME |
WEST DES MOINES |
POLK |
IOWA |
ERIN MONFORT NELSON |
COLE M. VAN LENT |
Signed |
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 |
665 |
2021-10-06 09:22 |
Anonymous (not verified) |
192.96.173.171 |
Michael Childers |
Proprietorship |
21 N.6th street savanna Illinois |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-06 |
Michael Childers |
peddler73@hotmail.com |
Savanna |
Carroll |
Illinois |
Brandy arnold |
Jordan nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas city |
Clay |
Mo |
Jordan nisiewicz |
Brandy arnold |
Signed |
777 |
2021-12-04 10:20 |
Anonymous (not verified) |
107.77.161.58 |
Martinez Painting |
Proprietorship |
3219 bowdoin st desmoines ia 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-04 |
Martinez Manuel |
Manuelitogladis29@gmail.com |
Desmoines |
Polk |
Iowa |
Yasco adilovic |
Samir radinovick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martinez Manuel |
Manuelitogladis29@gmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Yasco adilovic |
Samir radinovic |
Signed |
936 |
2022-02-25 10:47 |
Anonymous (not verified) |
173.215.112.17 |
Arganbright Home Construction LLC |
Limited Liability Company |
2251 Soldier Trail, Panora, IA 50216 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-25 |
David E Arganbright |
davearganbright@netins.net |
Panora |
Guthrie |
IA |
Cindy J Carstens |
Andrew Randol |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christine M Arganbright |
chrisbia@netins.net |
Member |
Panora |
Guthrie |
IA |
Cindy J Carstens |
Andrew Randol |
Signed |
1048 |
2022-04-14 14:17 |
Anonymous (not verified) |
208.38.229.255 |
Mean Green Lawn Care |
Limited Liability Company |
2628 W 59th st Davenport Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Anthony mccash |
meangreenlawncare20@gmail.com |
Davenport |
Scott |
Iowa |
Clarissa Oliva |
Julie Thornman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony McCash |
meangreenlawncare20@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Clarissa Oliva |
Julie Thornman |
Signed |
1847 |
2023-09-18 18:20 |
Anonymous (not verified) |
94.188.205.168 |
William O'Brien |
Proprietorship |
1069 Yukon Ave Sumner Iowa 50674 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-18 |
William Charles O'Brien |
wcobrien63@gmail.com |
Sumner |
Bremer |
Iowa |
Patrick B Dillon |
Christina Rader |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Charles O'Brien |
wcobrien63@gmail.com |
self |
Sumner |
Bremer |
Iowa |
Patrick B Dillon |
Christina Rader |
Signed |
1160 |
2022-06-20 10:08 |
Anonymous (not verified) |
138.43.237.249 |
High Caliber Fiber |
Limited Liability Company |
2958 110th ave masonville IA, 50654 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-20 |
chris cooper |
Chris_cooper@highcaliberfiber.com |
Masonville |
Delaware |
IA |
Laura Rose Lentz |
Blake Dean Elbert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Cooper |
Chris_cooper@highcaliberfiber.com |
self |
Masonville |
Delaware |
IA |
Laura Rose Lentz |
BLake Dean Elbert |
Signed |
1959 |
2023-12-15 13:32 |
Anonymous (not verified) |
94.188.205.169 |
DeFreeceBuilt LLC |
Limited Liability Company |
216 Rellim Dr Norwalk, IA 50211 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-15 |
Dylan DeFreece |
dylan@defreecebuiltia.com |
Norwalk |
Warren |
Iowa |
Abigail DeFreece |
Ricki Schroeder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dylan DeFreece |
dylan@defreecebuiltia.com |
N/A |
Norwalk |
Warren |
Iowa |
Abigail DeFreece |
Ricki Schroeder |
Signed |
1272 |
2022-08-19 09:36 |
Anonymous (not verified) |
75.162.65.221 |
William Jones |
Limited Liability Company |
1639 E 13th 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. |
2022-08-19 |
William Jones |
billjones1229@yahoo.com |
Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Jones |
billjones1229@yahoo.com |
Self |
Des Moines |
Polk |
Iowa |
Randy Lacina |
Laura Lacina |
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 |
1384 |
2022-12-08 13:11 |
Anonymous (not verified) |
172.58.81.43 |
Sehic G&S, LLC. |
Limited Liability Company |
4201 62nd st apt 4 Urbandale Ia 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-09 |
Bajro sehic |
kalesija20@gmail.com |
Urbandale |
Polk |
Iowa |
N/A |
N/A |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bajro sehic |
kalesija20@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
N/A |
N/A |
Signed |
9 |
2019-12-16 11:33 |
Anonymous (not verified) |
50.81.115.85 |
Travis Garrett and Caleb Elliott |
Partnership |
P.O. Box 55, Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-16 |
Travis Garrett |
onethird4599@gmail.com |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Garrett & Caleb Elliott |
onethird4599@gmail.com |
Owner |
Boone |
Boone |
IA |
Katie Frame |
Jessica Carroll |
Signed |
2183 |
2024-04-26 14:49 |
Anonymous (not verified) |
94.188.205.168 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-01 |
Jared Birkenholz |
jareddrewb@gmail.com |
CEDAR FALLS |
IA |
United States |
Colton Blue |
Kari Houle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cory Koger |
coryspainting@gmail.com |
Self |
CEDAR FALLS |
IA |
United States |
Colton Blue |
Kari Houle |
Signed |
1496 |
2023-03-06 11:24 |
Anonymous (not verified) |
94.188.207.227 |
Carrillo Drywall, LLC |
Limited Liability Company |
119 Marsh St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-06 |
Yesenia Carrillo |
yesecarrillo84@gmail.com |
Waterloo |
IA |
United States |
Rene Carrillo Jr |
Martha Basurto |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kyle Hildman |
kyleh@sinnottagency.com |
Insurance Agent |
Waterloo |
IA |
United States |
Rene Carrillo Jr |
Martha Basurto |
Signed |
121 |
2020-04-14 15:11 |
Anonymous (not verified) |
173.31.176.75 |
Society of St. Vincent de Paul, District council of Waterloo Iowa,Inc |
Limited Liability Company |
320 Broadway St PO Box 2727 Waterloo IA 50704 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-14 |
Michele E Collison |
darmstad48@aol.com |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joseph D. Sobczyk |
joczyk@aol.com |
Secretary of the St. Vincent de Paul District Council of Waterloo, Iowa, Inc. |
Denver |
Bremer |
Iowa |
George W. Karnick |
Glynis R. Worthington |
Signed |
1608 |
2023-04-26 11:51 |
Anonymous (not verified) |
94.188.205.167 |
Jesus Lozano |
Proprietorship |
1334 E 16th st Des Moines Iowa 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
Jesus Lozano |
Jesuslozano0086@icloud.com |
Des Moines |
Polk |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jesus Lozano |
Jesuslozano0086@icloud.com |
Owner |
Des Moines |
Polk |
Iowa |
Sheanah Wright |
Derek Mullins |
Signed |
233 |
2020-08-17 14:24 |
Anonymous (not verified) |
165.225.0.98 |
Daniel L Knebel |
Proprietorship |
439 Carroll Blvd, Dunkerton, IA, 50626 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-17 |
Daniel L Knebel |
knebeldan@gmail.com |
Dunkerton |
Black Hawk |
Iowa |
Carman M Knebel |
Joseph E Knebel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel L Knebel |
knebeldan@gmail.com |
Owner |
Dunkerton |
Black Hawk |
Iowa |
Carman M Knebel |
Joseph E Knebel |
Signed |
1720 |
2023-07-05 07:19 |
Anonymous (not verified) |
94.188.207.224 |
Doug FGerneding |
Proprietorship |
21618 270th St Carroll IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-05 |
Doug Ferneding |
dougferneding@gmail.com |
Carroll |
Iowa |
Iowa |
Jaynie Ferneding |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Doug Ferneding |
dougferneding@gmail.com |
same |
Carroll |
Iowa |
Iowa |
Jaynie Ferneding |
Brenda Klein |
Signed |
345 |
2020-12-29 09:20 |
Anonymous (not verified) |
173.18.16.129 |
Eben-Ezer Concrete Services |
Proprietorship |
1283 dixon 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. |
2020-12-29 |
Saul Artero |
Artro50313@yahoo.com |
Des Moines |
Polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Saul Artero |
Artro50313@yahoo.com |
owner |
des moines |
Polk |
Iowa |
Jen Lambert |
Lesa Reeves |
Signed |
457 |
2021-04-04 17:35 |
Anonymous (not verified) |
104.237.118.236 |
Lundt Transport, LLC |
Limited Liability Company |
3322 Y AVE. FAIRBANK, IA 50629 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-04 |
SAMUEL LUNDT |
samuelrl1998@gmail.com |
FAIRBANK |
Iowa |
Iowa |
CYNTHIA LUNDT |
KATLYN HILL |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAMUEL LUNDT |
samuelrl1998@gmail.com |
SELF |
FAIRBANK |
FAYETTE |
Iowa |
CYNTHIA LUNDT |
KATLYN HILL |
Signed |
569 |
2021-07-09 12:18 |
Anonymous (not verified) |
173.17.250.209 |
Forest Ave Outreach dba Good Vibes Movement |
Limited Liability Company |
1600 6th Ave DSM IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-09 |
Ben Spellman |
ben@goodvibesmovement.org |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maya Bromolson |
maya@goodvibesmovement.org |
Executive Director |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
681 |
2021-10-19 15:44 |
Anonymous (not verified) |
65.144.174.26 |
Humberto Albino |
Proprietorship |
3914 Aurora Ave Des Moines, IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-19 |
Humberto Albino |
albinohumberto73@gmail.com |
Des Moines |
Polk |
Iowa |
Miguel Albino |
Jesus Albino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Humberto Albino |
albinohumberto73@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Miguel Albino |
Jesus Albino |
Signed |
793 |
2021-12-14 14:16 |
Anonymous (not verified) |
174.22.96.99 |
Dubuque County Energy District |
Limited Liability Company |
700 Locust Street, #195 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-10 |
Michaela Marie Freiburger |
michaela@energydistrict.org |
Dubuque |
Dubuque |
IA |
Diane Freiburger, Mother |
Michael Freiburger, Father |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michaela Marie Freiburger |
michaela@energydistrict.org |
Contracted Vendor for the Dubuque County Energy District |
Dubuque |
Dubuque |
IA |
Diane Freiburger |
Michael Freiburger |
Signed |
952 |
2022-03-05 18:23 |
Anonymous (not verified) |
108.59.100.21 |
Heaven Sent PC LLC |
Limited Liability Company |
604 Allamakee St, Waukon,IA 52172 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-01 |
Justin Piggott |
heavensentpetcremation@gmail.com |
Waukon |
Allamakee |
Iowa |
Kaia Piggott |
Jane M Regan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Piggott |
heavensentpetcremation@gmail.com |
Member of LLC |
Waukon |
Allamakee |
Iowa |
Kaia Piggott |
Jane M Regan |
Signed |
1064 |
2022-04-21 12:48 |
Anonymous (not verified) |
174.199.77.87 |
Hocken Construction LLC |
Limited Liability Company |
926 State St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-01 |
Ryan Hocken |
ryan.hocken@yahoo.com |
Osage |
Mitchell |
Iowa |
Melissa Hocken |
Tyler Schwarck |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Hocken |
ryan.hocken@yahoo.com |
Owner |
Osage |
Mitchell |
Iowa |
Melissa Hocken |
Tyler Schwarck |
Signed |
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 |
1176 |
2022-07-05 08:08 |
Anonymous (not verified) |
64.251.168.116 |
Lucky Dude |
Proprietorship |
27656 SD Hwy 44 WHITE RIVER SD 57579 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-05 |
Lucky Dude |
agflyer620@gwtc.net |
White River |
Mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucky Dude |
agflyer620@gwtc.net |
proprietor |
White River |
mellette |
SD |
George Ludvik |
Julie Ludvik |
Signed |
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 |
1288 |
2022-08-30 16:23 |
Anonymous (not verified) |
50.83.35.94 |
Black Rock Flooring LLC |
Limited Liability Company |
189 9th st. Marion,Ia 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-30 |
Keith Douglas Luye Sr. |
Blackrockflooriing@gmail.com |
Marion |
Linn |
Iowa |
Cari Beth Lamb |
Daniel Ray Lamb |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Keith Douglas Luye Sr. |
Blackrockflooring@gmail.com |
self / my own authorized agent |
Marion |
Linn |
Iowa |
Cari Beth Lamb |
Daniel Ray Lamb |
Signed |
2087 |
2024-03-11 09:39 |
Anonymous (not verified) |
94.188.205.175 |
Shear Texture |
Limited Liability Company |
2000 Wiley Blvd SW |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-03-11 |
Wendy Kiser |
kiser187@msn.com |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Wendy Kiser |
kiser187@msn.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Kim Erickson |
Shauna Whitaker |
Signed |
1400 |
2022-12-22 10:02 |
Anonymous (not verified) |
166.196.110.105 |
It's a Breeze Cleaning Service |
Proprietorship |
760 W 8th Ave Marion, IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-22 |
Breonna Nelson |
breanderson82@yahoo.com |
Marion |
Linn |
Iowa |
Tyler Nelson |
Lisa Nelson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Breonna Nelson |
Breanderson82@yahoo.com |
Self |
Marion |
Linn |
IA |
Tyler Nelson |
Lisa Nelson |
Signed |
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 |
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 |
1512 |
2023-03-10 09:44 |
Anonymous (not verified) |
94.188.205.169 |
eliseo isai |
Proprietorship |
5301 SE 24th St Des Moines, IA 50320 United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-08 |
eliseo isai carranza perez |
Misaelballeza40@gmail.com |
desmoines |
polk |
iowa |
Julio Nolvela |
giovanni nolvela |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
eliseo isai carranza perez |
Misaelballeza40@gmail.com |
self |
desmoines |
polk |
iowa |
Julio Nolvela |
giovanni nolvela |
Signed |
137 |
2020-04-28 10:08 |
Anonymous (not verified) |
74.84.101.138 |
Nisse Preschool & Kids Place |
Partnership |
311 College Drive Decorah, IA 52101 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-26 |
Megan Sherman |
chelsea.whalen@upperiowains.com |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan Sherman |
chelsea.whalen@upperiowains.com |
President |
Decorah |
Winneshiek |
IA |
Michelle Ostern |
Robin C Schultz |
Signed |
1624 |
2023-05-03 10:30 |
Anonymous (not verified) |
94.188.207.227 |
Ryan Deymonaz |
Proprietorship |
2303 Kingsway Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-03 |
Ryan Deymonaz |
ryan.deymonaz@gmail.com |
Bettendorf |
Iowa |
United States |
Ryan Deymonaz |
Hannah Baker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Deymonaz |
ryan.deymonaz@gmail.com |
Self |
Bettendorf |
Iowa |
United States |
Ryan Deymonaz |
Hannah Baker |
Signed |
249 |
2020-08-28 13:06 |
Anonymous (not verified) |
97.125.184.147 |
Supernova Construction LLC |
Proprietorship |
4665 171st St, Urbandale, IA 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-08-28 |
Heraclio A Ayala |
heraclio.ayala@yahoo.com |
Urbandale |
Dallas |
IA |
Ricardo Alverio |
Valentin Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Heraclio Ayala |
heraclio.ayala@yahoo.com |
Sole Member |
Urbandale |
Dallas |
IA |
Ricardo Alverio |
Valentin Garcia |
Signed |
1736 |
2023-07-11 08:30 |
Anonymous (not verified) |
94.188.207.228 |
Scornos Waukee LLC |
Limited Liability Company |
286 w hickman rd waukee iowa 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-11 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
polk |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
owner |
des moines |
polk |
IOWA |
Liana Fatino |
Gary Fatino |
Signed |
361 |
2021-01-12 16:04 |
Anonymous (not verified) |
50.82.130.211 |
Gregory Lievens |
Partnership |
503 N. Main Street, Allison IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-12 |
Gregory Lievens |
cmins_re@mchsi.com |
Allison |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gregory Lievens |
cmins_re@mchsi.com |
Self |
Allison |
Butler |
Iowa |
Chad Campbell |
Roxanne Kolder |
Signed |
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 |
585 |
2021-07-25 20:07 |
Anonymous (not verified) |
75.162.247.154 |
CJNR Works, LLC |
Limited Liability Company |
17003 Bowdin Crest Drive, Cypress, Texas 77433 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-25 |
Christopher Ridgway |
christopherridgway@gmail.com |
Cypress |
Harris |
TX |
Sophia Ridgway |
Mitchel Monahan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christopher Ridgway |
christopherridgway@gmail.com |
Self |
Cypress |
Harris |
TX |
Sophia Ridgway |
Mitchel Monahan |
Signed |
697 |
2021-10-28 15:30 |
Anonymous (not verified) |
208.126.114.236 |
bartman express |
Limited Liability Company |
1976 240th st bennett iowa 52721 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-28 |
bartin joesph steines |
bartmanexpress@gmail.com |
bennett |
cedar |
iowa |
Robert theordore jarrett |
dana marie shipler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
bartin joesph steines |
bartmanexpress@gmail.com |
self |
bennett |
cedar |
iowa |
robert theordore jarrett |
dana marie shipler |
Signed |
809 |
2021-12-21 14:42 |
Anonymous (not verified) |
75.162.173.166 |
Mike Money |
Proprietorship |
3506 Glover Ave. Des Moines, Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-21 |
Michael David Money |
poojennings78@gmail.com |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Steve Jennings |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael David Money |
poojennings78@gmail.com |
self |
Des Moines |
Polk |
Iowa |
Diana Jennings |
Steve Jennings |
Signed |
968 |
2022-03-11 15:39 |
Anonymous (not verified) |
64.191.6.226 |
Wedeking Custom Comfort LLC |
Limited Liability Company |
17541 Ridge Ave Clarksville, IA 50619 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-11 |
Justin Wedeking |
wedeking42@gmail.com |
Clarksville |
Butler |
Iowa |
Jason Grant |
Richard Grant |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Wedeking |
wedeking42@gmail.com |
Self |
Clarksville |
butler |
Iowa |
Jason Grant |
Richard Grant |
Signed |
1767 |
2023-07-28 14:31 |
Anonymous (not verified) |
94.188.207.229 |
Kleckner Backhoe Service |
Proprietorship |
1302 S 1st St, Osage, IA 50461 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-28 |
Tracy S Kleckner |
terridkleckner@hotmail.com |
Osage |
Mitchell |
Iowa |
Robin Tabbert |
Jeannie Lemke |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
L R Falk Construction Co |
jeannie@lrfalk.com |
Dump Truck Hauler |
Osage |
Mitchell |
Iowa |
Robin Tabbert |
Jeannie Lemke |
Signed |