1874 |
2023-10-22 11:54 |
Anonymous (not verified) |
94.188.205.166 |
Midwest UAV LLC |
Limited Liability Company |
1400 15th St SE Bondurant Iowa 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-22 |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kaleb Thomas Trammell |
kttrammell05@gmail.com |
Owner |
Bondurant |
Polk |
IA |
Alan Willis |
Danielle Trammell |
Signed |
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 |
1920 |
2023-11-22 08:40 |
Anonymous (not verified) |
94.188.205.166 |
Demolition Services of Iowa, llc |
Limited Liability Company |
221 North Grant Ave., Elkhart, IA 50073 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-22 |
William Albert Halterman |
DemolitionServicesIA@gmail.com |
ELKHART |
IA |
United States |
Ashley Whitehill |
Zach Whitehill |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
William Albert Halterman |
DemolitionServicesIA@gmail.com |
self |
Elkhart |
Polk |
IA |
Ashley Nicole Lee Whitehill |
Zachery Allen Whitehill |
Signed |
1924 |
2023-11-27 12:17 |
Anonymous (not verified) |
94.188.205.166 |
Leaf Home LLC |
Limited Liability Company |
1595 Georgetown Rd. Hudson, OH 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-27 |
Nathaniel Brundidge |
nateotto1313@gmail.com |
Osceola |
Warren |
IA |
Barb Dryer |
Bob Dryer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Acosta |
macosta@leafhome.com |
Employee |
Hudson |
Summit |
Ohio |
Barb Dryer |
Bob Dryer |
Signed |
1957 |
2023-12-14 18:34 |
Anonymous (not verified) |
94.188.205.166 |
Renewal by Andersen |
Limited Liability Company |
5909 OMAHA AVE N STILLWATER, MN, 55082 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-14 |
Nicholas T Campbell |
hgchomes@gmail.com |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Kaut |
michael@rbadesmoines.com |
Employee |
Pleasant Hill |
Polk |
Iowa |
Randall D Campbell |
Lucas S Campbell |
Signed |
1982 |
2024-01-11 12:29 |
Anonymous (not verified) |
94.188.205.166 |
Grace Justine |
Proprietorship |
405 Northview Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-11 |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grace Justine Wandera / Independent Contractor |
justine.wandera@candeoiowa.org |
own |
Waukee |
IA |
IA |
Grace Justine Wandera / Independent Contractor |
Grace Justine Wandera / Independent Contractor |
Signed |
2011 |
2024-01-31 07:01 |
Anonymous (not verified) |
94.188.205.166 |
Goede Mechanical |
Limited Liability Company |
1607 10th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-31 |
Don Goede |
goedemechanical@gmail.com |
Harlan |
Shelby |
Iowa |
Dylan Goede |
Kallie Goede |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Don Goede |
goedemechanical@gmail.com |
Owner |
Harlan |
Shelby |
Iowa |
Dylan Goede |
Kallie Goede |
Signed |
2053 |
2024-02-22 11:29 |
Anonymous (not verified) |
94.188.205.166 |
Demir sehic |
Proprietorship |
4052 Lafayette road |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-22 |
Demir Sehic |
Demirsehic123@gamil.com |
Waterloo |
IA |
United States |
Jordan nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan nisiewicz |
jnisiewicz@leafhome.com |
Recurring |
Kansas city |
Jackson |
Mo |
Demir sehic |
Jordan Loyd |
Signed |
2061 |
2024-02-28 14:16 |
Anonymous (not verified) |
94.188.205.166 |
Cael Gulrud |
Proprietorship |
206 W Main St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-28 |
Cael Gulrud |
gulrud8728@gmail.com |
Calmar |
IA |
United States |
Belle Olsgard |
David Gulrud |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cael Gulrud |
gulrud8728@gmail.com |
Me |
Calmar |
IA |
United States |
Belle Olsgard |
David Gulrud |
Signed |
2065 |
2024-02-29 13:53 |
Anonymous (not verified) |
94.188.205.166 |
LEONARD BOUGHTON |
Partnership |
1616 AGENCY ST, BURLINGTON, IOWA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-29 |
LEONARD L BOUGHTON |
firstrate96@yahoo.com |
BURLINGTON |
DES MOINES |
IOWA |
PAM ZIPPE |
DEB SCOTT |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LEONARD L BOUGHTON |
firstrate96@yahoo.com |
Owner |
BURLINGTON |
DES MOINES |
IOWA |
PAM ZIPPE |
DEB SCOTT |
Signed |
2067 |
2024-02-29 16:58 |
Anonymous (not verified) |
94.188.205.166 |
James Baker |
Limited Liability Company |
1510 E 1st Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-01 |
James Baker |
jaykeribaker@yahoo.com |
Indianola |
Warren |
IA |
Keri Baker |
Brenan Baker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Baker |
jaykeribaker@yahoo.com |
Self |
Indianola |
Warren |
IA |
Keri Baker |
Brenan Baker |
Signed |
2079 |
2024-03-06 18:59 |
Anonymous (not verified) |
94.188.205.166 |
Maple Leaf Landscape Maintenance |
Proprietorship |
309 E. Exchange St Geneseo IL 61254 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-05 |
Chris Walters |
Mapleleaf@mapleleaflawnsolutions.com |
GENESEO |
IL |
United States |
Bobbi Jo Cox |
Victor Snook |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chris Walters |
mapleleaf@mapleleaflawnsolutions.com |
Self |
GENESEO |
IL |
United States |
Bobbi Jo Cox |
Victor Snook |
Signed |
2089 |
2024-03-12 10:58 |
Anonymous (not verified) |
94.188.205.166 |
Margarito R Guzman |
Proprietorship |
4512 S 22nd ST Omaha NE 68107 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-12 |
Margarito R Guzman |
abrahamguzman030@gmail.com |
omaha |
douglas |
NE |
jose abraham guzman garcia |
Drakkar Rapaich |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Margarito Guzman |
abrahamguzman030@gmail.com |
Owner |
Omaha |
Douglas |
Nebraksa |
jose abraham guzman garcia |
Drakkar Rapaich |
Signed |
2091 |
2024-03-12 15:23 |
Anonymous (not verified) |
94.188.205.166 |
Shelley onnen |
Proprietorship |
1319 West 2nd Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-12 |
Shelley L Onnen |
Shelleyonnen47@gmail.com |
PERRY |
IA |
United States |
Matthew Dean Rote |
Jerica Renae Wiborg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Shelley L Onnen |
Shelleyonnen47@gmail.com |
Self |
PERRY |
IA |
United States |
Matthew Dean Rote |
Jerica Renae Wiborg |
Signed |
2101 |
2024-03-18 09:21 |
Anonymous (not verified) |
94.188.205.166 |
Jason Tindle |
Proprietorship |
4103 1st St. Des Moines, Ia 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-18 |
Jason Tindle |
jtconstruction93@yahoo.com |
DES MOINES |
IOWA |
United States |
Zach Miller |
Nick Soma |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Tindle |
jtconstruction93@yahoo.com |
Myself |
Same |
Same |
Same |
Same |
Same |
Signed |
2113 |
2024-03-23 10:21 |
Anonymous (not verified) |
94.188.205.166 |
D2 Construction |
Limited Liability Company |
16192 wendover ave Madrid Ia 50156 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-23 |
Dillon Devine |
d2construction22@gmail.com |
Madrid |
Dallas |
Iowa |
Chelsey devine |
Jodie Gumm |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dillon devine |
d2construction22@gmail.com |
Self |
Madrid |
Dallas |
Iowa |
Chelsey devine |
Jodie gumm |
Signed |
2132 |
2024-04-03 19:49 |
Anonymous (not verified) |
94.188.205.166 |
Soto Stone LLC |
Limited Liability Partnership |
1071 mansfield Dr waukee iowa 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-04-03 |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Yesser Lenin Juarez Soto |
sotostonellc95@gmail.com |
self |
waukee |
Dallas |
Iowa |
Ashley Marie Francisco |
Vincent Alexander Flores |
Signed |
2147 |
2024-04-12 11:52 |
Anonymous (not verified) |
94.188.205.166 |
Tri County Enterprise |
Partnership |
5527 Crane Lane NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-12 |
Ken McGraw |
kenmcgraw1974@gmail.com |
Center Point |
IA |
United States |
bob nissen |
Jenny Vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Shellsburg |
IA |
United States |
bob Nissen |
Jenny Vaske |
Signed |
2156 |
2024-04-16 17:00 |
Anonymous (not verified) |
94.188.205.166 |
BONILLA STONE LLC |
Limited Liability Company |
3201 COLUMBIA ST DES MOINES, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-16 |
JAIRO JAVIER BONILLA SERRANO |
jairobonilla509@gmail.com |
DES MOINES |
POLK |
IOWA |
ROCIO REYES |
JOSE HERNANDEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JAIRO JAVIER BONILLA SERRANO |
jairobonilla509@gmail.com |
SAME |
DES MOINES |
POLK |
IOWA |
ROCIO REYES |
JOSE HERNANDEZ |
Signed |
2169 |
2024-04-22 09:49 |
Anonymous (not verified) |
94.188.205.166 |
Galatic Service LLC |
Proprietorship |
623 1st street silvis IL 61282 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Marcos Gonzales |
Marcosg300@yahoo.com |
Silvis |
Rock Island |
IL |
Jordan lyod |
Jordan Nisiewicz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas city |
Johnson |
MO |
Marcos Gonzales |
Jordan Lyod |
Signed |
2173 |
2024-04-23 14:19 |
Anonymous (not verified) |
94.188.205.166 |
Duer and Sons Remodeling, Inc |
Partnership |
1795 Se 82nd St, Runnells Iowa 50237 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-23 |
John Duer |
John@duerandsonsremodeling.com |
Runnells |
Polk |
Iowa |
Travis Justice |
Jake VanGorp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
John Duer |
John@duerandsonsremodeling.com |
Owner |
Runnells |
Polk |
Iowa |
Travis Justice |
Jake VanGorp |
Signed |
2184 |
2024-04-26 15:03 |
Anonymous (not verified) |
94.188.205.166 |
Cory's Painting LLC |
Limited Liability Company |
Po Box 1161, Cedar Falls, Iowa 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-15 |
Joseph Abrahamson |
abrahamsonjd95@gmail.com |
Readlyn |
Bremer |
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 |
Blackhawk |
Iowa |
Colton Blue |
Kari Houle |
Signed |
2185 |
2024-04-26 16:46 |
Anonymous (not verified) |
94.188.205.166 |
Jerilyn Horn Kitchen and Bath Design Co. |
Proprietorship |
413 Jefferson St., Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-26 |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerilyn Michelle Horn |
designsbyjerilyn@gmail.com |
owner |
Mt. Pleasant |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
2192 |
2024-04-29 13:15 |
Anonymous (not verified) |
94.188.205.166 |
ElmStreet Apothecary |
Limited Liability Company |
320 W Kimberly Road #227 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
Erica McGee |
esalsbury07@gmail.com |
Bettendorf |
Scott |
Ia |
Jennifer West |
Julie Francis |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erica McGee |
esalsbury07@gmail.com |
Self |
Bettendorf |
Scott |
Ia |
Jennifer West |
Julie Francis |
Signed |
2195 |
2024-04-30 15:31 |
Anonymous (not verified) |
94.188.205.166 |
Jason Cooper |
Proprietorship |
1181 Western Ave Stockton Iowa 52769 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-30 |
Jason cooper |
jvcpainting88@gmail.com |
Stockton |
IA |
United States |
Violet minssen |
Hope Bishop |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason cooper |
jvcpainting88@gmail.com |
Self |
Stockton |
IA |
United States |
Violet minssen |
Hope Bishop |
Signed |
2206 |
2024-05-07 09:10 |
Anonymous (not verified) |
94.188.205.166 |
Stephanie Farmer |
Proprietorship |
600 6th Ave, Marion, IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-07 |
Stephanie Farmer |
farmer.stephanie22@gmail.com |
Marion |
Linn |
IA |
Chris Farmer |
Deb Hartz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Farmer |
farmer.stephanie22@gmail.com |
Self |
Marion |
Linn |
IA |
Chris Farmer |
Deb Hartz |
Signed |
1725 |
2023-07-07 13:37 |
Anonymous (not verified) |
94.188.205.167 |
Liana Fatino |
Limited Liability Company |
1930 se 14th des moines iowa 50321 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-07 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
USA |
Iowa |
Liana Fatino |
Gary Fatino |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Liana Fatino |
lfatino@yahoo.com |
wife |
des moines |
USA |
iowa |
Liana Fatino |
Gary Fatino |
Signed |
1811 |
2023-08-21 17:03 |
Anonymous (not verified) |
94.188.205.167 |
Cardinal Concrete LLC |
Limited Liability Company |
503 17th St Boone, IA 50036 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-21 |
Ryan Woods |
cardinalconcrete.cw@gmail.com |
Boone |
Boone |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Woods |
cardinalconcrete.cw@gmail.com |
100% owner |
Boone |
Boone |
Iowa |
Jon Buller |
Terry Miles |
Signed |
1839 |
2023-09-12 11:22 |
Anonymous (not verified) |
94.188.205.167 |
J.S. Reeves Consulting LLC |
Limited Liability Company |
1610 1st Ave, Perry, IA 50220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-12 |
joni Sue Reeves |
jonisreeves@att.net |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joni Sue Reeves |
jsreeves67@gmail.com |
Same |
Perry |
IA |
United States |
Maggie Rhodes |
Barb Butler |
Signed |
1843 |
2023-09-14 14:12 |
Anonymous (not verified) |
94.188.205.167 |
Rosenbum Construction, LLC |
Limited Liability Company |
720 South Street, Arlington, Iowa 50606 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-02 |
Thomas Rosenbum |
tomdolly1126@yahoo.com |
Arlington |
Fayette |
Iowa |
Dolly Rosenbum |
Steve Frost |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Rosenbum |
tomdolly1126@yahoo.com |
Self |
Arlington |
Fayette |
Iowa |
Dolly Rosenbum |
Steve Frost |
Signed |
1859 |
2023-10-04 07:54 |
Anonymous (not verified) |
94.188.205.167 |
Pacheco Constructrion |
Limited Liability Company |
1614 Center Street, Des Moines 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. |
2023-10-04 |
Ulises Pacheco |
info@pachecoconstruction.com |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ulises Pacheco |
info@pachecoconstruction.com |
Self |
Des Moines |
Polk |
Iowa |
Melissa Gray |
Darci Rene Pacheco |
Signed |
1880 |
2023-10-26 13:24 |
Anonymous (not verified) |
94.188.205.167 |
Brown Remodel & Construction LLC |
Limited Liability Company |
7819 Evans St Mingo iowa 50168 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-26 |
Matthew Ray Brown |
brownremodel@gmail.com |
Mingo |
Jasper |
Iowa |
Rebecca Lynn Brown |
Michael Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Ray Brown |
brownremodel@gmail.com |
Self |
Mingo |
Jasper |
Iowa |
Rebecca lynn Brown |
Michael Moore |
Signed |
1894 |
2023-11-03 10:02 |
Anonymous (not verified) |
94.188.205.167 |
ASHLEY QUAIL DBA: RUSTIC ROOTS SALON |
Proprietorship |
33596 SCHANY DR, RUTHVEN, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-03 |
ASHLEY QUAIL |
ashley-mazzanti@hotmail.com |
RUTHVEN |
PALO ALTO |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ASHLEY QUAIL |
ashley-mazzanti@hotmail.com |
SELF |
RUTHVEN |
PALO ALTO |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1905 |
2023-11-13 21:35 |
Anonymous (not verified) |
94.188.205.167 |
Bartolo Lopez |
Limited Liability Company |
2404 cass st Fort Worth tx 76112 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-13 |
Bartolo Lopez |
bartololopez3737@gmail.com |
Fort Worth tx |
Tarrant county |
Tx |
Airan Zamudio |
Carlos Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bartolo Lopez |
bartololopez3737@mail.com |
Boss of the company |
Fort Worth |
Tarrant county |
Texas |
Airan Zamudio |
Carlos lopez |
Signed |
1913 |
2023-11-20 13:48 |
Anonymous (not verified) |
94.188.205.167 |
KWF SALES INC |
Proprietorship |
216 WINDFLOWER LANE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-20 |
KRISTI A WOODLEY-FLANSBURG |
Kwflansburg@gmail.com |
SOLON |
Iowa |
Iowa |
ZACH GRANT |
TOM SIMPSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KRISTI A WOODLEY-FLANSBURG |
Kwflansburg@gmail.com |
SELF |
SOLON |
IA |
IA |
ZACH GRANT |
TOM SIMPSON |
Signed |
1918 |
2023-11-21 12:45 |
Anonymous (not verified) |
94.188.205.167 |
515 PAINTING LLC |
Limited Liability Company |
PO Box 157, Berwick, IA 50032 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-01 |
Marvin Parker |
gcort06@gmail.com |
Berwick |
Polk |
Iowa |
Dillon Parker |
Gary Cort |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Parker |
gcort06@gmail.com |
Owner |
Berwick |
Polk |
Iowa |
Dillon Parket |
Gary Cort |
Signed |
1941 |
2023-12-06 11:52 |
Anonymous (not verified) |
94.188.205.167 |
GUEVARA CONCRETE LLC |
Limited Liability Company |
26 WESTVIEW DR APT 5 MILFORD, IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
MILFORD |
DICKINSON |
IA |
TAMI SUE KLEIN |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
SAUL GUEVARA MEZA |
ESMEJ2513@GMAIL.COM |
SELF |
MILFORD |
DICKINSON |
IA |
TAMI SUE KLEIN |
JENNIFER JANET YOUNGWIRTH |
Signed |
1952 |
2023-12-12 13:26 |
Anonymous (not verified) |
94.188.205.167 |
Austin Albin |
Proprietorship |
2263 Railroad Street, Jacksonville, IL 62650 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-23 |
Austin R Albin |
albinaustin12@gmail.com |
Jacksonville |
Morgan |
IL |
Wayne Albin |
Jerry Roth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin R Albin |
albinaustin12@gmail.com |
Self |
Jacksonville |
Morgan |
IL |
Wayne Albin |
Jerry Roth |
Signed |
1974 |
2024-01-04 13:12 |
Anonymous (not verified) |
94.188.205.167 |
Cro Outdoor Services, LLC |
Limited Liability Company |
1616 NW 78TH 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. |
2023-12-20 |
Bojan Djukic |
Croodsia@gmail.com |
Clive |
Iowa |
United States |
Cezar Villalobos |
Maria Villalobos |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evetee Villalobos |
e.villalobos91@gmail.com |
s/o |
Clive |
IA |
United States |
Maria Villalobos |
Cezar Villalobos |
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 |
1979 |
2024-01-08 14:59 |
Anonymous (not verified) |
94.188.205.167 |
Nathan Troendle |
Proprietorship |
Lansing 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. |
2024-01-05 |
Nathan Troendle |
darrele@ciains.biz |
Lansing |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nathan Troendle |
darrele@ciains.biz |
self |
Lansing |
Allamakee |
Iowa |
Chris Fye |
Darrel Elsbernd |
Signed |
1985 |
2024-01-16 11:51 |
Anonymous (not verified) |
94.188.205.167 |
Wasabi Urbandale LLC |
Limited Liability Company |
5106 155th Street, Urbandale, IA 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-16 |
Yean Ching Sue |
soamie@hotmail.com |
Urbandale |
Dallas |
Iowa |
Enjin Zheng |
Wen Zheng |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Yean Ching Sue |
soamie@hotmail.com |
Owner |
Urbandale |
Dallas |
Iowa |
Enjin Zheng |
Wen Zheng |
Signed |
1995 |
2024-01-23 15:08 |
Anonymous (not verified) |
94.188.205.167 |
Spencer Abbott |
Proprietorship |
1358 170th Ave, Murray Iowa 50174 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Spencer Abbott |
sabbott1800@gmail.com |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Spencer Abbott |
sabbott1800@gmail.com |
sole proprietor |
Murray |
Clarke |
Iowa |
Juanita Yutzy |
Elaine Lee |
Signed |
2013 |
2024-01-31 15:14 |
Anonymous (not verified) |
94.188.205.167 |
Aspen Ridge LLC |
Limited Liability Company |
1404 G Ave Marengo, IA 52301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Jeffrey McKusker |
jeff@mckuskerelectric.com |
Marengo |
Iowa |
Iowa |
Karly Kovar |
Jacob McKusker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori McKusker |
jeff@mckuskerelectric.com |
Spouse |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
2019 |
2024-02-01 15:23 |
Anonymous (not verified) |
94.188.205.167 |
SolQ LLC |
Limited Liability Company |
184 N 100 E STE A Logan, UT 84321 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-01 |
wyatt phelps |
wyatt@solq.com |
Eagle Mountain |
UT |
United States |
Perry M Koger |
Rebecca Koger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
wyatt phelps |
wyatt@solq.com |
Owner |
Eagle Mountain |
UT |
United States |
Perry M Koker |
Rebecca Koger |
Signed |
2038 |
2024-02-08 07:44 |
Anonymous (not verified) |
94.188.205.167 |
Travis Toney |
Limited Liability Company |
932 w12th street south newton ia 50208 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Travis Duane Toney |
travistoney1984@gmail.com |
Newton |
United States |
IA |
Rick lee Toney |
Brenda Ann Toney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Phil glazer |
kg_Info@capitallandscaping.com |
Contractor |
Des Moines |
United States |
IA |
Rick lee Toney |
Brenda Ann Toney |
Signed |
2070 |
2024-03-01 10:21 |
Anonymous (not verified) |
94.188.205.167 |
J&W siding LLC |
Limited Liability Company |
302 West Lincoln street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-01 |
william t Belz |
5.4tritonf150@gmail.com |
Walcott |
IA |
IA |
william t Belz |
william t Belz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
william t Belz |
5.4tritonf150@gmail.com |
owner |
Walcott |
IA |
IA |
william t Belz |
william t Belz |
Signed |
2081 |
2024-03-08 10:44 |
Anonymous (not verified) |
94.188.205.167 |
T & S Sandblasting and Painting LLC |
Limited Liability Company |
101 Clinton ST Corwith IA 50430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-08 |
Matthew Tindall |
matt.tindall83@gmail.com |
Corwith |
Hancock |
IA |
Wendy S Jensen |
Jason Bradley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Tindall |
matt.tindall83@gmail.com |
self |
Corwith |
Hancock |
IA |
Wendy S Jensen |
Jason Bradley |
Signed |
2100 |
2024-03-17 12:36 |
Anonymous (not verified) |
94.188.205.167 |
Donovan Electric LLC |
Limited Liability Company |
857 Tipperary rd Iowa City iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-17 |
Bill Donovan |
bill@donovanelectricllc.com |
Iowa City |
Johnson |
IA |
Bo Nock |
Stephanie Ineichen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Donovan |
blaked@donovanelectricllc.com |
Partner |
Iowa City |
Johnson |
IA |
Bo Nock |
Stephanie Ineichen |
Signed |
2104 |
2024-03-18 12:36 |
Anonymous (not verified) |
94.188.205.167 |
Scornoos 1973 INC |
Proprietorship |
8561 hickman rd urbandale iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
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 |
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 |
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 |
2142 |
2024-04-09 09:39 |
Anonymous (not verified) |
94.188.205.167 |
Bart Fuller & james Fuller DBA Fuller & Sons |
Partnership |
1302 Lincoln Street Ruthven, IA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-09 |
James Fuller |
goffins@ruthventel.com |
Ruthven |
Pal Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Fuller |
goffins@ruthventel.com |
Partner |
Ruthven |
Palo Alto |
Iowa |
Kathryn Kelley |
Janice Henningsen |
Signed |
2153 |
2024-04-15 21:59 |
Anonymous (not verified) |
94.188.205.167 |
Ethan M Hoffman |
Proprietorship |
1442 N. County RD 800, Hamilton, IL 62341 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-07 |
Ethan M Hoffman |
kellylanz1967@gmail.com |
Hamilton |
IL |
United States |
Gay Hoffman |
Debra Kelley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ethan M Hoffman |
kellylanz1967@gmail.com |
Self |
Hamilton |
IL |
United States |
Gay Hoffman |
Debra Kelley |
Signed |
2164 |
2024-04-19 13:52 |
Anonymous (not verified) |
94.188.205.167 |
RKB Designs LLC |
Limited Liability Company |
4333 Cedar St, Davenport, IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-19 |
Ashley Rocca |
roccafive@gmail.com |
Davenport |
IA |
United States |
Nicholas Rocca |
Joni Long |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ashley Rocca |
roccafive@gmail.com |
Self |
Davenport |
IA |
United States |
Nicholas Rocca |
Joni Long |
Signed |
2172 |
2024-04-22 14:09 |
Anonymous (not verified) |
94.188.205.167 |
Melissa J Madison |
Proprietorship |
326 NE Olivewood Waukee, IA 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Melissa Janelle Madison |
melissamadison01@gmail.com |
Waukee |
DALLAS |
IOWA |
Haley Sears |
Scott Leinen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Madison |
melissamadison01@gmail.com |
myself |
Waukee |
Dallas |
Iowa |
Haley Sears |
Scott Leinen |
Signed |
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 |
1458 |
2023-02-16 07:20 |
Anonymous (not verified) |
94.188.205.167 |
Windsor Earth Works, dba Wells Commercial Flooring |
Limited Liability Company |
1442 73rd Street, Windsor Heights, Ia. 50324 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-16 |
Timothy E Wells |
wellsba1@msn.com |
Windsor Heights |
Polk |
Iowa |
Leonard Klug |
Barbara Wells |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Barbara Wells |
wellsba65@gmail.com |
Spouse |
Windsor Heights |
Polk |
Iowa |
Leonard Klug |
Timothy Wells |
Signed |
1470 |
2023-02-20 08:38 |
Anonymous (not verified) |
94.188.205.167 |
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. |
2023-02-20 |
Alison Vice |
orders@level92.com |
Indianola |
Warren |
Iowa |
Bill Bauer |
Cindy Bauer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alison Vice |
orders@level92.com |
Partner |
Indianola |
Warren |
Iowa |
Bill Bauer |
Cindy Bauer |
Signed |
1501 |
2023-03-07 11:27 |
Anonymous (not verified) |
94.188.205.167 |
Adriene Dangler |
Proprietorship |
2400 South Shore Dr Clear Lake, IA 50428 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Adrienne Dangler |
darrele@ciains.biz |
Clear Lake |
Cerro Gordo |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Darrel Elsbernd |
darrele@ciains.biz |
agent |
Clear Lake |
Cerro Gordo |
Iowa |
Darrel Elsbernd |
Chris Fye |
Signed |
1520 |
2023-03-16 14:24 |
Anonymous (not verified) |
94.188.205.167 |
MMK Electric |
Partnership |
4515 84th Street Urbandale, Iowa 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-16 |
Marshall Logan McKay |
mmk.iowa@gmail.com |
Des Moines |
Polk |
Iowa |
Travis Miller |
Elijah Kain |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Miller |
mmk.iowa@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Elijah Kain |
Travis Miller |
Signed |
1527 |
2023-03-22 08:35 |
Anonymous (not verified) |
94.188.205.167 |
Quad Cities Transport Inc |
Proprietorship |
1106 46th ave Rock Island IL 61201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-21 |
Howard Rick Clark Davis |
hdenterprisesinc14@gmail.com |
East Moline |
Rock Island |
IL |
Patrick Watkins |
Ricky Oconner |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Howard Davis |
qctransportinc@gmail.com |
Owner |
East Moline |
Rock Island |
Illinois |
Ricky Oconner |
Patrick Watkins |
Signed |
1534 |
2023-03-27 08:16 |
Anonymous (not verified) |
94.188.205.167 |
Richatd Deist |
Proprietorship |
1445 Hwy 71 Audubon IA 50025 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-26 |
Richard Deist |
deistfarms@hotmail.com |
Audubon |
IA |
United States |
Tara Deist |
Pat Groth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bob Miller |
bob.miller@millerhybrids.com |
seed dealer |
Kalona ,Ia |
Washington |
IA |
Tara Deist |
Pat Groth |
Signed |
1535 |
2023-03-27 09:40 |
Anonymous (not verified) |
94.188.205.167 |
Richard Deist |
Proprietorship |
1445 hwy 71 Audubon Ia 50025 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-26 |
Richard Deist |
deistfarms@hotmail.com |
Audubon |
Audubon |
IA |
Tara Deist |
Pat Groth |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bob Miller |
bob.miller@millerhybrids.com |
Seed dealer |
Kalona |
Washington |
IA |
Tara Deist |
Pat Groth |
Signed |
1538 |
2023-03-27 15:20 |
Anonymous (not verified) |
94.188.205.167 |
Luke Woods |
Limited Liability Company |
1513 Burnett Station Road Central City, IA 52214 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-27 |
Luke James Woods |
woodsmencontractingllc@gmail.com |
Central City |
Linn |
Iowa |
Keith John Woods |
Heath John Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke James Woods |
woodsmencontractingllc@gmail.com |
same person |
Central City |
Linn |
Iowa |
Keith John Woods |
Heath John Woods |
Signed |
1572 |
2023-04-13 11:12 |
Anonymous (not verified) |
94.188.205.167 |
CK Trucking |
Proprietorship |
24497 Hayes Street, Pleasantville, Iowa 50225 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-13 |
Craig Kooyman |
dmsstumpguy@yahoo.com |
Pleasantville |
IA |
IA |
Chad Randleman |
James Jordan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Craig Kooyman |
dmsstumpguy@yahoo.com |
Owner |
Pleasantville |
Warren |
IA |
Chad Randleman |
James Jordan |
Signed |
1573 |
2023-04-14 13:43 |
Anonymous (not verified) |
94.188.205.167 |
Jaxon Kressley |
Proprietorship |
954 Boston Way, #12, Corralville, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-14 |
Jaxon Kressley |
jaxon@optionsexteriors.com |
Corralville |
Johnson |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaxon Kressley |
jaxon@optionsexteriors.com |
Owner/Self |
Corralville |
Johnson |
Iowa |
Charlotte Rasmussen |
Austin Miller |
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 |
1577 |
2023-04-17 09:58 |
Anonymous (not verified) |
94.188.205.167 |
Four Leaf LLC |
Limited Liability Company |
11150 NE 72nd St Bondurant IA 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-17 |
Eric O'Shea |
Fourleaf2021@gmail.com |
Bondurant |
IA |
United States |
Lucas Gray |
Curt Decker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Eric Michael O'Shea |
Fourleaf2021@gmail.com |
Owner |
Bondurant |
IA |
United States |
Lucas Gray |
Curt Decker |
Signed |
1580 |
2023-04-17 20:22 |
Anonymous (not verified) |
94.188.205.167 |
Lance Van Der weerd |
Limited Liability Company |
909 S Adams Street Rock Rapids IA 51246 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-17 |
Lance Van Der Weerd |
enterprisesvdw@gmail.com |
Rock Rapids |
IA |
United States |
Brittany Van Der Weerd |
Todd Mienerts |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lance Van Der Weerd |
enterprisesvdw@gmail.com |
Myself |
Rock Rapids |
Lyon |
Iowa |
Brittany Van Der Weerd |
Todd Mienerts |
Signed |
1585 |
2023-04-18 14:04 |
Anonymous (not verified) |
94.188.205.167 |
L&J Services LLC |
Limited Liability Company |
6 highland acres rd marshalltown iowa 50158 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-18 |
Josh Colwell |
centraliowa@fibrenew.com |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolinsger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josh Colwell |
centraliowa@fibrenew.com |
Owner |
Marshalltown |
IA |
United States |
Micah Hesse |
Hunter Bolsinger |
Signed |
1589 |
2023-04-20 12:57 |
Anonymous (not verified) |
94.188.205.167 |
Grace Flooring |
Proprietorship |
2001 W 2nd Street perry, Iowa 50220 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-20 |
Ryan Michael Tool |
GraceFlooring0@gmail.com |
Perry |
Dallas |
IA |
Jennifer Lynn Tool |
Shane Workman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Grace Flooring |
GraceFlooring0@gmail.com |
Owner |
Perry |
Dallas |
IA |
Jennifer Tool |
Shane workman |
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 |
1618 |
2023-04-28 11:10 |
Anonymous (not verified) |
94.188.205.167 |
Hunter Flying Service, LLC |
Limited Liability Company |
PO Box 215 Hunter, AR 72074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-28 |
James Lynn Cary |
hunterflying@att.net |
Hunter |
Woodruff |
Arkansas |
Karen Gifford |
Jason White |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Lynn Cary |
hunterflying@att.net |
Self |
Hunter |
Woodruff |
AR |
Karen Gifford |
Jason White |
Signed |
1636 |
2023-05-10 07:31 |
Anonymous (not verified) |
94.188.205.167 |
Brad Bower Drywall LLC |
Limited Liability Company |
209 Northridge West Branch, IA 52358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Bradley Bower |
bbower74@gmail.com |
West Branch |
Cedar |
Iowa |
Kirk Strunk |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brad Bower |
bbower74@gmail.com |
Self |
West Branch |
Cedar |
Iowa |
Kirk Strunk |
Chris Hay |
Signed |
1652 |
2023-05-17 20:44 |
Anonymous (not verified) |
94.188.205.167 |
Fox Trucking |
Proprietorship |
2774 March Ave Greene Ia. 50636 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-17 |
Chet D. Fox |
cjakfox@yahoo.com |
Greene |
Floyd |
Iowa |
Jack Dwyer |
Chad Olson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chet Fox |
cjakfox@yahoo.com |
myself |
Greene |
Floyd |
Iowa |
Jack Dwyer |
Chad Olson |
Signed |
1661 |
2023-05-24 10:12 |
Anonymous (not verified) |
94.188.205.167 |
Might Lawn Care |
Limited Liability Company |
1920 W 70th St. Davenport, IA 52806 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-24 |
Samuel Lawrence Might |
mightlawncare@gmail.com |
Davenport |
Scott |
IA |
Meredith Might |
Suzette Henriksen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Samuel Might |
mightlawncare@gmail.com |
Owner |
Davenport |
Scott |
IA |
Meredith Might |
Suzette Henriksen |
Signed |
1663 |
2023-05-25 12:56 |
Anonymous (not verified) |
94.188.205.167 |
Affordable Painting and Renovations of Iowa LLC |
Limited Liability Company |
1417 NW Applewood 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. |
2023-05-25 |
Bryan Thieleke |
affordablerenoiowa@yahoo.com |
Ankeny |
Polk |
Iowa |
Mike kaut |
Adam lozano |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryan Thieleke |
affordablerenoiowa@yahoo.com |
Owner |
Ankeny |
Polk |
Iowa |
Mike kaut |
Adam lozano |
Signed |
1698 |
2023-06-20 16:43 |
Anonymous (not verified) |
94.188.205.167 |
Mike farrell |
Proprietorship |
306 ne trilein dr ankeny,ia 50021 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-20 |
Michael David farrell |
farrellsfmr@yahoo.com |
Ankeny |
Polk |
Ia |
ERICK SCHULST |
Kelly Coluzzi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael David farrell |
farrellsfmr@yahoo.com |
Owner |
Ankeny |
Polk |
Iowa |
Erick Schuldr |
Kelly .Coluzzi3 |
Signed |
1712 |
2023-06-26 20:33 |
Anonymous (not verified) |
94.188.205.167 |
Eastern Iowa Overhead Door |
Proprietorship |
120 N Eliza Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-26 |
Tim Chapin |
easterniadoor@gmail.com |
Maquoketa |
IA |
United States |
Carri Lee Waack |
Wendy Marie Zaruba |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tim Chapin |
easterniadoor@gmail.com |
Owner |
Maquoketa |
Jackson |
United States |
Carri Lee Waack |
Wendy Marie Zaruba |
Signed |
1714 |
2023-06-27 09:14 |
Anonymous (not verified) |
94.188.205.167 |
Meier Trucking LLC |
Limited Liability Company |
35032 308th St, Bellevue, IA 52031 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-14 |
Brandon Meier |
meierturcking87@yahoo.com |
Bellevue |
Jackson |
Iowa |
Susan Miller |
Nicole Mensen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brandon Meier |
meiertrucking87@yahoo.com |
self |
Bellevue |
Jackson |
Iowa |
Susan Miller |
Nicole Mensen |
Signed |
1450 |
2023-02-11 10:59 |
Anonymous (not verified) |
94.188.205.168 |
JOSE G OLIVAREZ |
Limited Liability Company |
1529 11TH ST DES MOINES 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. |
2023-02-11 |
JOSE G OLIVAREZ |
joseolivares742@gmail.com |
DES MOINES |
POLK |
IOWA |
SAMIR RAHMANOVIC |
SAMIR RAHMANOVIC |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
none |
joseolivares742@gmail.com |
none |
DES MOINES |
POLK |
IOWA |
samir rahmanovic |
samir rahmanovic |
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 |
1456 |
2023-02-15 13:12 |
Anonymous (not verified) |
94.188.205.168 |
Bloodgood construction services |
Proprietorship |
4422 happy trail prole ia 50229 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-15 |
Alan Dean bloodgood |
alanbloodgood@gmail.com |
Prole |
Warren |
Ia |
Derek bloodgood |
Albert bloodgood |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bloodgood construction services |
alanbloodgood@gmail.com |
Self |
Prole |
Warren |
Ia |
Derek bloodgood |
Albert bloodgood |
Signed |
1461 |
2023-02-17 07:48 |
Anonymous (not verified) |
94.188.205.168 |
Great Blinds LLC |
Limited Liability Company |
5174 Parkridge Ave Pleasant Hill, IA 50327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Andrew Mohrfeld |
mohrfeldandy@yahoo.com |
Pleasant Hill |
Polk |
IA |
Andrew Mohrfeld |
Martin Mohrfeld |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
John Lovell |
Jon@jlovellco.com |
None |
Urbandale |
Polk |
IA |
Andrew Mohrfeld |
Martin Mohrfeld |
Signed |
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 |
1552 |
2023-04-03 13:58 |
Anonymous (not verified) |
94.188.205.168 |
F&I Drywall Llc |
Limited Liability Company |
509 Arlington Dr. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-03 |
Fernando Garcia |
Fgarcia1989.fg@gmail.com |
Marshalltown |
Marshall |
Iowa |
Gabriela Garcia |
Araceli Tafolla |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Fernando Garcia |
Fgarcia1989.fg@gmail.com |
Self |
Marshalltown |
Marshall |
Iowa |
Gabriela Garcia |
Araceli Tafolla |
Signed |
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 |
1590 |
2023-04-21 07:10 |
Anonymous (not verified) |
94.188.205.168 |
Diamond Spray Foam & Coatings LLC |
Limited Liability Company |
19024 345th St, Forest City, IA 50436 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-21 |
Joshua G Diamond |
dsfinsulation@gmail.com |
Forest City |
Iowa |
United States |
Greg Diamond |
Renee Diamond |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua G Diamond |
dsfinsulation@gmail.com |
Owner |
Forest City |
Iowa |
United States |
Greg Diamond |
Renee Diamond |
Signed |
1609 |
2023-04-26 11:58 |
Anonymous (not verified) |
94.188.205.168 |
edwin gonzalez |
Proprietorship |
115 e ayers st osceola ia 50213 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-26 |
edwin gonzalez |
lrestrada83@gmail.com |
osceola |
Clark |
ia |
Sheanah Wright |
Derek Mullins |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
edwin gonzalez |
lrestrada83@gmail.com |
owner |
osceola |
clarke |
ia |
Sheanah Wright |
Derek Mullins |
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 |
1633 |
2023-05-09 15:46 |
Anonymous (not verified) |
94.188.205.168 |
Unique Painting, LLC |
Partnership |
2500 E. 39Th Court |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-09 |
Ricardo Rodriguez Perfecto |
uniquepainting00@gmail.com |
Des Moines |
USA |
IOWA |
Oseas Diaz |
Jorge Corona |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ricardo Rodriguez Perfecto |
uniquepainting00@gmail.com |
Vice president |
Des Moines |
USA |
IOWA |
Oseas Diaz |
Jorge Corona |
Signed |
1640 |
2023-05-11 07:42 |
Anonymous (not verified) |
94.188.205.168 |
Ibarra Drywall LLC |
Proprietorship |
1991 Holiday Rd, Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-11 |
Juan Reyes Ibarra |
juanreyes22031979@gmail.com |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Reyes Ibarra |
juanreyes22031979@gmail.com |
Self |
Coralville |
Johnson |
Iowa |
Arcel Servin |
Chris Hay |
Signed |
1658 |
2023-05-23 09:56 |
Anonymous (not verified) |
94.188.205.168 |
M&D Webster Construction Inc |
Proprietorship |
1012 Creek Street Webster City IA 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-28 |
David Gomez |
office.seamlesspros@icloud.com |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
David Gomez |
office.seamlesspros@icloud.com |
Self |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
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 |
1678 |
2023-06-06 08:13 |
Anonymous (not verified) |
94.188.205.168 |
Castor Construction |
Limited Liability Company |
1515 Avenue O Fort Dodge, Iowa 50501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-06 |
Kit Hovey |
hoveykit@gmail.com |
FORT DODGE |
Webster |
United States |
Alexis Malm |
Kit Hovey |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Noah Carspecken |
noah@castorconstructionco.com |
Management |
FORT DODGE |
Webster |
United States |
Alexis Malm |
Kit Hovey |
Signed |
1680 |
2023-06-06 12:08 |
Anonymous (not verified) |
94.188.205.168 |
Sipac Drywall |
Proprietorship |
1130 Columbia St, Waterloo, IA 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-06 |
Jennifer Sipac |
jenniferyoung164@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Augie Ferguson |
Wendy Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jennifer Sipac |
jenniferyoung164@gmail.com |
Owner |
Waterloo |
Black Hawk |
Iowa |
Augie Ferguson |
Wendy Phillips |
Signed |
1726 |
2023-07-07 18:22 |
Anonymous (not verified) |
94.188.205.168 |
D&E LLC DBA Kanesville Valley |
Limited Liability Company |
P.O. Box 337 Council Bluffs, IA, 51502 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-07 |
Damien Joseph Shull |
damienshull@gmail.com |
Omaha |
Douglas |
Nebraska |
Angela Shull |
John Shull |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Damien Joseph Shull |
damienshull@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Angela Shull |
John Shull |
Signed |
1740 |
2023-07-11 12:22 |
Anonymous (not verified) |
94.188.205.168 |
Innovators Construction LLC |
Limited Liability Company |
3234 180th St., Homestead, IA 52236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-11 |
Guadalupe Ramirez |
imfo@jmdrywallonline.com |
Homestead |
Iowa |
Iowa |
Itali Ramírez |
Juan m Ramírez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan M Ramírez |
info@jmdrywallonline.com |
Business partner |
Homestead |
Iowa |
Iowa |
Itali Ramírez |
Juan m Ramírez |
Signed |
1753 |
2023-07-18 14:41 |
Anonymous (not verified) |
94.188.205.168 |
Cruz Lerma |
Proprietorship |
1439 17th Ct 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. |
2023-07-18 |
Cruz Lerma |
deb@picowa.com |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly K Denger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cruz Lerma |
deb@piciowa.com |
self |
Des Moines |
Polk |
Iowa |
Deb Stratton |
Kelly K Denger |
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 |
1772 |
2023-08-01 15:09 |
Anonymous (not verified) |
94.188.205.168 |
MHI Services |
Proprietorship |
613 Damon St Council Bluffs, IA 51503 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-01 |
Lisa Mitchell |
lmitchell939@gmail.com |
Council Bluffs |
Pottawattamie |
Iowa |
Charles Meckna |
Christopher Young |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LIsa MItchellj |
lmitchell939@gmail.com |
Self |
Council Bluffs |
Pottawattamie |
Iowa |
Charles Meckna |
Christopher Young |
Signed |
1774 |
2023-08-03 08:40 |
Anonymous (not verified) |
94.188.205.168 |
J P Trucking, Inc. |
Proprietorship |
8768 White Tail Lane, 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. |
2021-08-03 |
Jamison Noel |
jptrucking.jamison@gmail.com |
Dubuque |
DBQ |
Iowa |
Lindsay Noel |
Andy Kemp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jamison Noel |
jptrucking.jamison@gmail.com |
Owner |
Dubuque |
Dubuque |
Iowa |
Lindsay Noel |
Andy Kemp |
Signed |
1788 |
2023-08-07 18:32 |
Anonymous (not verified) |
94.188.205.168 |
Johnson Custom Paint & Design LLC |
Limited Liability Company |
1414 N 9TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-07 |
Josh Johnson |
johnsoncustompaint@hotmail.com |
Fort Dodge |
Iowa |
United States |
JACKLYN JOHNSON |
Roger Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joshua Johnson |
johnsoncustompaint@hotmail.com |
owner |
Fort Dodge |
IA |
United States |
JACKLYN JOHNSON |
Roger Johnson |
Signed |
1801 |
2023-08-15 14:17 |
Anonymous (not verified) |
94.188.205.168 |
Mark S Lisiecki |
Proprietorship |
2526 S Arizona RD Apache Junction AZ 85119 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Mark S Lisiecki |
markslisiecki@yahoo.com |
Apache Junction |
PINAL |
Arizona |
Simona Valeriano |
Cindy Ugarte |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Lisiecki |
markslisiecki@yahoo.com |
owner |
APACHE jUNCTION |
PINAL |
AZ |
Simona Valeriano |
Cindy Ugarte |
Signed |
1808 |
2023-08-17 17:17 |
Anonymous (not verified) |
94.188.205.168 |
Treimer Trucking LLC |
Limited Liability Company |
3277 102nd St. Durant, IA 52747-9524 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-17 |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Tipton |
Iowa |
United States |
Sydney Rae Lane |
Spencer Lea Parsons |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Dennis Treimer |
dtreimer65@gmail.com |
Self |
Tipton |
Iowa |
United States |
Syndey Rae Lane |
Spencer Lea Parsons |
Signed |
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 |
1878 |
2023-10-26 09:06 |
Anonymous (not verified) |
94.188.205.168 |
Jones Facility Maintenance |
Limited Liability Company |
3929 Council Street NE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-25 |
Mason Jones |
jonesmason546@gmail.com |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mason Bradley Jones |
jonesmason546@gmail.com |
Owner |
Cedar Rapids |
IA |
United States |
Lindsey Jones |
Seth Wennermark |
Signed |
1907 |
2023-11-15 09:45 |
Anonymous (not verified) |
94.188.205.168 |
Dan Taylor |
Proprietorship |
1422 State ST. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-15 |
Daniel Taylor |
mailrunner1958@gmail.com |
Mason City |
Cerro Gordo |
IA |
Bob Smith |
Dave Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Daniel Taylor |
mailrunner1958@gmail.com |
employee |
Mason City |
Cerro Gordo |
IA |
Bob Smith |
Dave Clark |
Signed |
1928 |
2023-11-29 21:48 |
Anonymous (not verified) |
94.188.205.168 |
Iowa Evolution Constuction |
Partnership |
1203 Bluegrass Cir |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Claudia Rodriguez |
claudia.rodriguez.213@gmail.com |
CEDAR FALLS |
IA |
United States |
Guillermo Nunez |
Blanca rodriguez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Claudia Rodriguez |
claudia.rodriguez.213@gmail.com |
Owner |
CEDAR FALLS |
IA |
United States |
Guillermo Nunez |
Blanca Rodriguez |
Signed |
1932 |
2023-12-01 20:02 |
Anonymous (not verified) |
94.188.205.168 |
Wasabi Johnston LLC |
Limited Liability Company |
2965 SE Timberline dr, Waukee, IA, 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-01 |
Enjin zheng |
jimmyzheng1573@gmail.com |
Waukee |
Dallas |
Iowa |
Jenna Yu |
Wen Zheng |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Enjin zheng |
jimmyzheng1573@gmail.com |
Owner |
Waukee |
Dallas |
Iowa |
Jenna Yu |
Wen Zheng |
Signed |
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 |
1950 |
2023-12-12 12:20 |
Anonymous (not verified) |
94.188.205.168 |
Central Iowa Welding & Repair |
Limited Liability Company |
13913 140th Avenue |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-01 |
Trevor Campbell |
centraliowaweldingrepair@gmail.com |
Indianola |
Warren |
Iowa |
Amber Campbell |
Jake Snow |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Trevor Campbell |
centraliowaweldingrepair@gmail.com |
Owner |
Indianola |
Warren |
Iowa |
Amber Campbell |
Jake Snow |
Signed |
1958 |
2023-12-15 12:26 |
Anonymous (not verified) |
94.188.205.168 |
Big & Steinke Construction |
Limited Liability Company |
1737 B Avenue NE Cedar Rapids, Iowa 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-15 |
Jordan Bigbee |
bigandsteinkeconstruction@gmail.com |
Cedar Rapids |
Iowa |
United States |
Zachary Steinke |
Taylor Bigbee |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zachary Steinke |
bigandsteinkeconstruction@gmail.com |
Owner |
Cedar Rapids |
Iowa |
United States |
Jordan Bigbee |
Taylor Bigbee |
Signed |
1970 |
2023-12-29 10:01 |
Anonymous (not verified) |
94.188.205.168 |
Beatrice Banura |
Proprietorship |
14511 Bentwood Dr, Urbandale IA 50323 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-29 |
Beatrice Banura |
banurabeatrice4@gmail.com |
Urbandale |
Dallas |
IA |
Priscilla Saina |
Gideon Saina |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Beatrice Banura |
banurabeatrice4@gmail.com |
Self employed |
Urbandale |
IA |
IA |
Priscilla Saina |
Gideon Saina |
Signed |
1983 |
2024-01-11 13:02 |
Anonymous (not verified) |
94.188.205.168 |
r&k propety solutions |
Proprietorship |
po box 53 cedar rapids iowa 52406 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-11 |
roy rohwedder |
rohwedder.roy@yahoo.com |
Cedar Rapids |
linn |
ia |
Brian Ashlock |
tim vaske |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Brian Ashlock |
brian@tricounty-iowa.com |
General Manager |
Center Point |
Benton |
ia |
Tim Vaske |
Roy Rohwedder |
Signed |
1989 |
2024-01-16 17:13 |
Anonymous (not verified) |
94.188.205.168 |
Xcel Electric LLC |
Limited Liability Company |
1142 Columbus Dr Waterloo Ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-16 |
Haris Mumic |
h.mumic@hotmail.com |
Waterloo |
Black Hawk |
IA |
Minea Skrgic-Mumic |
Elvis Mumic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Haris Mumic |
h.mumic@hotmail.com |
Owner/Employer |
waterloo |
Black Hawk |
IA |
Minea Skrgic-Mumic |
Elvis Mumic |
Signed |
1990 |
2024-01-16 22:22 |
Anonymous (not verified) |
94.188.205.168 |
DeltaPro Painting & Remodeling |
Limited Liability Company |
1115 Nolan Court North Liberty 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. |
2024-01-16 |
Bayron Amador |
bayronamador59@gmail.com |
North Liberty |
IA |
Estados Unidos |
Claudia Garmendia |
Marlon Amador |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bayron Amador |
bayronamador59@gmail.com |
Owner/Employer |
North Liberty |
IA |
Estados Unidos |
Claudia Garmendia |
Marlon Amador |
Signed |
1993 |
2024-01-23 07:36 |
Anonymous (not verified) |
94.188.205.168 |
Leaf Home Solutions LLC |
Limited Liability Partnership |
1595 Georgetown Road Hudson, OH 44236 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-23 |
Michael Rice |
wildblueed@gmail.com |
Middle Amana |
Iowa |
Iowa |
Sylvia Rice |
Russel Hospadarsky |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Acosta |
macosta@leafhome.com |
recruiter |
Hudson |
Summit |
Ohio |
Sylvia Rice |
Russel Hospadarsky |
Signed |
1998 |
2024-01-25 16:18 |
Anonymous (not verified) |
94.188.205.168 |
Faith and Trust Soulutions LLC |
Limited Liability Company |
139 37th Street NE Suite # 2 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-25 |
Marie Moore |
faithandtrustsoulutionsllc@gmail.com |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Arthur Barbine |
faithandtrustsoulutionsllc@gmail.com |
Friend |
Cedar Rapids |
Iowa |
United States |
Arthur Barbine |
Arthur Barbine |
Signed |
2033 |
2024-02-07 11:38 |
Anonymous (not verified) |
94.188.205.168 |
JENKINS CONSTRUCTION |
Proprietorship |
315 NORTH MAIN STREET, P.O. BOX 124, ODEBOLT, IA 51458 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-07 |
DENNIS CHARLES JENKINS |
dcjmjenkins@yahoo.com |
ODEBOLT |
SAC |
IOWA |
ROBERT EUGENE BELT |
JOHN CLARENCE OLERICH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DENNIS CHARLES JENKINS |
dcjmjenkins@yahoo.com |
SELF |
ODEBOLT |
SAC |
IOWA |
ROBERT EUGENE BELT |
JOHN CLARENCE OLERICH |
Signed |
2044 |
2024-02-15 09:52 |
Anonymous (not verified) |
94.188.205.168 |
Messenger Trucking LLC |
Limited Liability Company |
1869 255th St., Fairfield, IA 52556 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-08 |
Timothy Duncan Messenger |
tmessengertrucking@gmail.com |
Fairfield |
Jefferson |
Iowa |
Casey Messenger |
Bud Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy Duncan Messenger |
tmessengertrucking@gmail.com |
Self |
Fairfield |
Jefferson |
Iowa |
Casey Messenger |
Bud Smith |
Signed |
2080 |
2024-03-07 12:57 |
Anonymous (not verified) |
94.188.205.168 |
Will's Bus Stuff LLC |
Limited Liability Company |
402 SE Grant St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-07 |
Will Boettcher |
wboettcher@centurionstoneofiowa.com |
Des Moines |
Iowa |
United States |
Tyler Franklin |
Troy Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Will Boettcher |
willsbusstuffllc@gmail.com |
Owner |
Ankeny |
Iowa |
United States |
Tyler Franklin |
Troy Klein |
Signed |
2096 |
2024-03-14 14:53 |
Anonymous (not verified) |
94.188.205.168 |
Scott Allen |
Proprietorship |
2603 Bryant 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. |
2024-03-14 |
Scott Michael Allen |
allen.scottm@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Daniel Bryant Bliek |
Jennifer Lee Allen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Michael Allen |
allen.scottm@gmail.com |
Self |
Cedar Rapids |
Linn |
Iowa |
Daniel Bryant Bliek |
Jennifer Lee Allen |
Signed |
2111 |
2024-03-21 14:28 |
Anonymous (not verified) |
94.188.205.168 |
James Watson |
Limited Liability Company |
4708 71st Street Urbandale, Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-24 |
James Edward watson |
junior99@email.com |
Urbandale |
IA |
United States |
Susie Givant |
Doug Frame |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jason Lantz |
jason@lantzelite.com |
Employer |
Urbandale |
IA |
United States |
Susie Givant |
Doug Frame |
Signed |
2131 |
2024-04-02 10:28 |
Anonymous (not verified) |
94.188.205.168 |
Driskell Spray, LLC |
Limited Liability Company |
1279 300th Ave Sidney, IA 51652 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-22 |
Jamie Driskell |
driskell216@gmail.com |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jamie Driskell |
driskell216@gmail.com |
owner |
Sidney |
Fremont |
Iowa |
Melinda Goy |
Rhett Goy |
Signed |
2139 |
2024-04-08 10:35 |
Anonymous (not verified) |
94.188.205.168 |
Professional Hardwood Floors LLC |
Limited Liability Company |
14858 118th Ave, Indianola, IA 50125 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-08 |
Ivan Pilat |
professionalfloors@ymail.com |
Indianola |
Warren |
iowa |
Mark Kapysten |
Vladmir Orbedan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ivan Pilat |
professionalfloors@ymail.com |
Self |
Indianola |
Warren |
Iowa |
Mark Kapysten |
Vladmir Orbedan |
Signed |
2157 |
2024-04-17 11:16 |
Anonymous (not verified) |
94.188.205.168 |
LAKESIDE DETAILING LLC |
Limited Liability Company |
249 EMERALD MEADOWS DR, ARNOLDS PARK, IA 51331 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-17 |
DYLAN MCHUGH |
19DMCHUGH@GMAIL.COM |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
DYLAN MCHUGH |
19DMCHUGH@GMAIL.COM |
SELF |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
2181 |
2024-04-25 15:41 |
Anonymous (not verified) |
94.188.205.168 |
Ev's Ice Cream LLC |
Limited Liability Company |
2205 1/2 S Center St, Marshalltown, IA 50158-5960 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-25 |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kathryn Perry-Jenkins |
hawkeyesfan.22.kp@gmail.com |
Self |
Marshalltown |
Marshall |
IA |
Rebecca Houg |
Dakota Himes |
Signed |
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 |
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 |
2190 |
2024-04-29 09:28 |
Anonymous (not verified) |
94.188.205.168 |
JOHNSON OHANA LLC |
Limited Liability Company |
145 GREENBRIER DR, BURLINGTON, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-29 |
JARED JOHNSON |
KONAOHANAICE@GMAIL.COM |
BURINGTON |
DES MOINES |
IOWA |
MARCY KNAUSS |
MATTHEW RINKER |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MAGGIE JOHNSON |
KONAOHANAICE@GMAIL.COM |
PARTNER/SPOUSE |
BURLINGTON |
DES MOINES |
IOWA |
MARCY KNAUSS |
MATTHEW RINKER |
Signed |
2193 |
2024-04-30 11:37 |
Anonymous (not verified) |
94.188.205.168 |
Hausman Dozing LLC |
Limited Liability Company |
24860 230th St Carroll, Iowa 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. |
2024-04-30 |
Jess Jonathan Hausman |
hausmandozing@gmail.com |
Carroll |
Carroll |
IOWA |
Jeff Dentlinger |
Lauren Brauckman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jess Hausman |
hausmandozing@gmail.com |
Owner |
Carroll |
Carroll |
IOWA |
Jeff Dentlinger |
Lauren Brauckman |
Signed |
2204 |
2024-05-06 18:56 |
Anonymous (not verified) |
94.188.205.168 |
Jim saukko |
Proprietorship |
13232 nw 30 th st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-05 |
Jim Saukko |
saukkogt500@gmail.com |
Polk city |
IA |
United States |
Dawn brown |
Kirk moser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jim Saukko |
saukkogt500@gmail.com |
Self |
Polk city |
IA |
IA |
Dawn brown |
Kirk moser |
Signed |
2214 |
2024-05-08 13:49 |
Anonymous (not verified) |
94.188.205.168 |
Hagen Installation Solutions LLC |
Limited Liability Company |
725 Cole St Carlisle, IA 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-08 |
Clay Allen Hagen |
clay.hagenson@gmail.com |
Carlisle |
Warren |
Iowa |
Tyler Bumgardner |
Spencer Kissinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clay Allen Hagen |
clay.hagenson@gmail.com |
Same person |
Carlisle |
Warren |
Iowa |
Tyler Bumgardner |
Spencer Kissinger |
Signed |
1727 |
2023-07-07 18:26 |
Anonymous (not verified) |
94.188.205.169 |
D&E LLC DBA Kanesville Valley |
Limited Liability Company |
P.O. Box 337 Council Bluffs, IA, 51502 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-07 |
Edward Gregory |
eddegregory@gmail.com |
Council Bluffs |
Pottawattamie |
Iowa |
Natasha Gregory |
Stanley Gregory |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Edward Gregory |
eddegregory@gmail.com |
Self |
Council Bluffs |
Pottawattamie |
Iowa |
Natasha Gregory |
Stanley Gregory |
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 |
1756 |
2023-07-20 11:19 |
Anonymous (not verified) |
94.188.205.169 |
LEVI GONZALEZ |
Proprietorship |
2212 OKOBOJI AVE MILFORD, IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-13 |
LEVI GONZALEZ |
joel@walkerinsuranceia.com |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LEVI GONZALEZ |
JOEL@WALKERINSURANCEIA.COM |
SELF |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI KLEIN |
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 |
1794 |
2023-08-10 14:56 |
Anonymous (not verified) |
94.188.205.169 |
Alex Kiler |
Proprietorship |
10511 Main Road, La Porte City, IA 50651, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-10 |
Alex Kiler |
alexkiler12622@gmail.com |
La Porte City, IA |
Black Hawk County |
Iowa |
Charles Woods |
Steve Geisler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Charles Wood |
Steven Geisler |
Signed |
1821 |
2023-08-29 10:11 |
Anonymous (not verified) |
94.188.205.169 |
Des Moines Smart Solutions LLC |
Limited Liability Company |
1329 56th St., Des Moines, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-29 |
Denzel Colocho |
alejandro_colocho@yahoo.com |
Des Moines |
Polk |
Iowa |
Steve Webb |
Austin Kelderman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Des Moines Smart Solutions LLC |
alejandro_colocho@yahoo.com |
Owner |
Des Moines |
Polk |
Iowa |
Steve Webb |
Austin Kelderman |
Signed |
1857 |
2023-10-02 16:33 |
Anonymous (not verified) |
94.188.205.169 |
Noah Blount |
Proprietorship |
2611 capitol ave, Des Moines, IA 50317, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-02 |
Noah Blount |
nbeav5@gmail.com |
Des Moines |
Des Moines |
Iowa |
Jordan Loyd |
Charles Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Jackson |
Missouri |
Jordan Loyd |
Charles Woods |
Signed |
1871 |
2023-10-18 10:27 |
Anonymous (not verified) |
94.188.205.169 |
Derik Gonyier |
Proprietorship |
1421 Chicago Ave, Savanna, IL 61074 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-14 |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Savanna |
Carroll |
IL |
Kyle Lee Sturtz |
Daryl Gonyier |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Derik Ray Gonyier |
deriknalexis121413@gmail.com |
Self |
Savanna |
Carroll |
IL |
Kylee Lee |
Daryl Eugene Gonyier |
Signed |
1876 |
2023-10-23 14:26 |
Anonymous (not verified) |
94.188.205.169 |
Magnus, LLC |
Limited Liability Company |
1120 2nd Street SE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-23 |
Kristina Link |
magnina@aol.com |
Cedar Rapids |
IA |
IA |
Shannon Thompson |
Jeff Spies |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kristina Link |
magnina@aol.com |
business owner |
Cedar Rapids |
Iowa |
Iowa |
Shannon Thompson |
Jeff Spies |
Signed |
1892 |
2023-11-02 12:24 |
Anonymous (not verified) |
94.188.205.169 |
TREJO'S CONSTRUCTION LLC |
Limited Liability Company |
1113 L AVE, MILFORD, IA 51351 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-02 |
CHARVEL TREJO |
levrach@yahoo.com |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
CHARVEL TREJO |
levrach@yahoo.com |
SELF |
MILFORD |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1945 |
2023-12-06 16:47 |
Anonymous (not verified) |
94.188.205.169 |
Sell Now Iowa |
Limited Liability Company |
5525 Meredith Drive Suite B Des Moines Iowa 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-06 |
Alejandro Bacano Rodriguez |
alejandrobacanorodriguez@gmail.com |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sell Now Iowa |
team@sellnowiowa.com |
None |
Des Moines |
Polk |
Iowa |
Breny Rodriguez |
Gabriela Martinez |
Signed |
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 |
2003 |
2024-01-28 12:38 |
Anonymous (not verified) |
94.188.205.169 |
Wasabi Urbandale LLC |
Limited Liability Company |
2301 Rocklyn Dr, Urbandale IA 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-01 |
Jay Wang |
jaywang@wasabidsm.com |
Clive |
Dallas |
IA |
Ajdin Nadarich |
Jeremy Boysen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jay Wang |
jaywang@wasabidsm.com |
Self |
Clive |
Dallas |
IA |
Lisa Lee |
Yingna Zheng |
Signed |
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 |
2049 |
2024-02-16 09:19 |
Anonymous (not verified) |
94.188.205.169 |
Cadona Construction LLC |
Limited Liability Company |
215 S Leonard, Sioux City, IA 51103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-16 |
Luis Cardona |
luiscardona5151@gmail.com |
Sioux City |
Woodbury |
Iowa |
Kyle Buum |
David Jacobs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis Cardona |
luiscardona5151@gmail.com |
Owner |
Sioux City |
Woodbury |
Iowa |
Kyle Buum |
David Jacobs |
Signed |
2059 |
2024-02-27 11:44 |
Anonymous (not verified) |
94.188.205.169 |
Dowdey Construction LLC |
Limited Liability Company |
1010 19th Ave - Rock Valley, IA 51247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-27 |
Nicholas Allen Dowdey |
nddowdey@hotmail.com |
Rock Valley |
Sioux |
Iowa |
Deidre Dawn Dowdey |
Alexander C Koedam |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Nicholas Allen Dowdey |
nddowdey@hotmail.com |
Self |
Rock Valley |
Sioux |
Iowa |
Deidre Dawn Dowdey |
Alexander C Koedam |
Signed |
2062 |
2024-02-29 08:25 |
Anonymous (not verified) |
94.188.205.169 |
Midwest Splicing LLC |
Limited Liability Company |
1803 N HALF BANK RD , Stringtown , OK 74569 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-29 |
James Xiong |
midwestsplicing71@yahoo.com |
Stringtown |
OKLAHOMA |
OKLAHOMA |
Vang Pao Chang |
Xia Vang |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
James Xiong |
midwestsplicing71@yahoo.com |
owner |
STRINGTOWN |
Oklahoma |
Oklahoma |
xia Vang |
Vang Pao Chang |
Signed |
2083 |
2024-03-08 14:41 |
Anonymous (not verified) |
94.188.205.169 |
Michael Dwayne Wahl Jr DBA Dents Etc |
Proprietorship |
3458 Highway 65/69, Carlisle, Iowa 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-08 |
Michael Dwayne Wahl Jr |
darrin@fisherbodypaint.com |
Carlisle |
Polk |
Iowa |
Darrin Morrison |
Anthony Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Schreck |
mark.schreck@insurancestationinc.com |
Agent |
Altoona |
IA |
IA |
Darrin Morrison |
Anthony Garcia |
Signed |
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 |
2105 |
2024-03-18 12:45 |
Anonymous (not verified) |
94.188.205.169 |
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 |
Liana Fatino |
lfatino@yahoo.com |
des moines |
POLK |
IOWA |
GARY FATINO |
LISA VACCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
GARY FATINO |
lfatino@yahoo.com |
husband |
des moines |
polk |
iowa |
Gary Fatino |
Lisa Vacco |
Signed |
2109 |
2024-03-21 11:15 |
Anonymous (not verified) |
94.188.205.169 |
Panameno Stone |
Proprietorship |
3701 SE 18th Ct. Des Moines, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-21 |
Domingo Panameno |
albertpana08@gmail.com |
Des Moines |
Polk |
Iowa |
Drakkar Rapaich |
Fabi Palomares |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Domingo Panameno |
albertpana08@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Drakkar Rapaich |
Fabi Palomares |
Signed |
2119 |
2024-03-27 14:27 |
Anonymous (not verified) |
94.188.205.169 |
juan garcia |
Proprietorship |
3359 Patrick Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-27 |
Juan Garcia |
garcia.stone2022@gmail.com |
omaha |
Douglas |
Nebraska |
Ashlee Virves |
Reyna Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Juan Garcia |
garcia.stone2022@gmail.com |
Self |
Omaha |
Douglas |
Nebraska |
Ashlee Virves |
Reyna Garcia |
Signed |
2120 |
2024-03-27 15:31 |
Anonymous (not verified) |
94.188.205.169 |
Dustin pleshe |
Proprietorship |
6855 woodland ave unit 505 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-27 |
Dustin Pleshe |
dustinjpleshe@gmail.com |
WEST DES MOINES |
Iowa |
United States |
Kasey Cunningham |
Kathy Cunningham |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dustin Pleshe |
dustinjpleshe@gmail.com |
He is me |
WEST DES MOINES |
Iowa |
United States |
Kasey cunningham |
Kathy cunningham |
Signed |
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 |
2134 |
2024-04-04 08:10 |
Anonymous (not verified) |
94.188.205.169 |
TERRA CONSTRUCTION LLC |
Limited Liability Company |
621 Oak Park Ave Des Moines, IA 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-04-04 |
Bryce Shabazz |
block.radio@yahoo.com |
Des Moines |
Polk |
Iowa |
Megan Donigan |
George Hana |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jessica L Heller |
Jessica.heller@adp.com |
Insurance Agent |
Allentown |
Lehigh |
PA |
Megan Donigan |
George Hana |
Signed |
2136 |
2024-04-04 16:08 |
Anonymous (not verified) |
94.188.205.169 |
Elite Construction & Masonry LLC |
Limited Liability Company |
3309 Wright St Des Moines IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-04 |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Manuel Mejia |
eliteconstructionmasonryllc@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2180 |
2024-04-25 14:19 |
Anonymous (not verified) |
94.188.205.169 |
Stems Flower Shop, LLC |
Limited Liability Company |
515 8th St SE |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-22 |
Stephanie Groom |
stephanie.groom@stemsiowa.com |
Altoona |
Polk |
Iowa |
Kelli Kerton |
Tyler Ingle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Groom |
stephanie.groom@stemsiowa.com |
Self - Business Owner |
Altoona |
Polk |
Iowa |
Kelli Kerton |
Tyler Ingle |
Signed |
2208 |
2024-05-07 12:44 |
Anonymous (not verified) |
94.188.205.169 |
Tom Franklin |
Proprietorship |
2353 Salem Road, New London, IA 52645 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-05-07 |
Thomas Eric Franklin |
68carpetman@gmail.com |
New London |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Thomas Eric Franklin |
68carpetman@gmail.com |
owner |
New London |
Henry |
Iowa |
Cheryl Ross |
Larry Rheinschmidt |
Signed |
1467 |
2023-02-17 16:14 |
Anonymous (not verified) |
94.188.205.169 |
H & C Construction |
Limited Liability Company |
708 Vine Street Lucas IA 50151 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Colton Charles Clarke |
ccclarke95@gmail.com |
Truro |
IA |
United States |
Hailey Sullivan |
Shelby Comer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
H & C Construction |
ccclarke95@gmail.com |
Manager |
Truro |
IA |
United States |
Hailey Sullivan |
Shelby Comer |
Signed |
1469 |
2023-02-19 18:23 |
Anonymous (not verified) |
94.188.205.169 |
Superior Sheet Metal LLC |
Limited Liability Company |
1819 MM Ave Marengo, IA 52301 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-19 |
Adam Lynn Nielsen |
adamnielsen4@yahoo.com |
Marengo |
Iowa |
United States |
Emily Jean Nielsen |
Joseph Daryl Kriegel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adam Lynn Nielsen |
adamnielsen4@yahoo.com |
Self |
Marengo |
Iowa |
Iowa |
Emily Jean Nielsen |
Joseph Daryl Kriegel |
Signed |
1471 |
2023-02-20 10:24 |
Anonymous (not verified) |
94.188.205.169 |
Vega Investments |
Limited Liability Company |
330 NE 72nd Street, Pleasant Hill, IA 50327 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-20 |
Stephanie Westrom |
stephanie.westrom@microsoft.com |
Pleasant Hill |
Polk |
Iowa |
Thomas Westrom |
Jean Schnake |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Stephanie Westrom |
stephanie.westrom@microsoft.com |
Owner |
Pleasant Hill |
Polk |
Iowa |
Thomas Westrom |
Jean Schnake |
Signed |
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 |
1513 |
2023-03-13 06:54 |
Anonymous (not verified) |
94.188.205.169 |
Tyler Ankney |
Proprietorship |
1250 A Avenue, Marion, IA 52302, 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. |
2023-03-13 |
Tyler Ankney |
T_james55@ahoo.com |
Marion |
Linn County |
Iowa |
Jordan Nisiewicz |
Steve Gisler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Steve Gisler |
Signed |
1556 |
2023-04-05 14:08 |
Anonymous (not verified) |
94.188.205.169 |
Capstone Staffing Solutions LLC |
Limited Liability Company |
315 E 5th St, STE 202, Waterloo, IA, 50703 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-05 |
Peterson Munyasia |
pete@capstonestaffingsolutions.com |
Allen |
USA |
TX |
Daniel Mwangi |
Elizabeth Munene |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Peterson Munyasia |
pete@capstonestaffingsolutions.com |
Owner |
Allen |
USA |
TX |
Daniel Mwangi |
Elizabeth Munene |
Signed |
1566 |
2023-04-12 08:40 |
Anonymous (not verified) |
94.188.205.169 |
Sabokwigura Jonathan |
Proprietorship |
1613 12th Avenue Southeast, Cedar Rapids, IA 52401, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-12 |
Sabokwigura Jonathan |
nzobojo@gmail.com |
Cedar Rapids |
Linn County |
Iowa |
Jordan Nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Robert Snyder |
Signed |
1586 |
2023-04-19 08:38 |
Anonymous (not verified) |
94.188.205.169 |
Arcos Siding, LLC |
Limited Liability Company |
1429 22nd Street, Des Moines, IA 50311 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-19 |
Alfredo Arco Cruz |
alfredoarcos13@gmail.com |
Des Moines |
Polk |
Des Moines |
Maria Sevillana Cruz |
Miguel Sevillana |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Alfredo Arcos Cruz |
alfredoarco13@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Maria Sevillana Cruz |
Miguel Sevillana |
Signed |
1587 |
2023-04-19 09:12 |
Anonymous (not verified) |
94.188.205.169 |
Sami Jo T Tappe |
Proprietorship |
7044 Carey Ct Johnston, IA 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-19 |
Sami Jo Tappe |
samijotappe@gmail.com |
Johnston |
Polk |
Iowa |
Olga Sanchez |
Matthew Tappe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Sami Jo Tappe |
samijotappe@gmail.com |
Self |
Johnston |
Polk |
Iowa |
Olga Sanchez |
Matthew Tappe |
Signed |
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 |
1642 |
2023-05-12 07:29 |
Anonymous (not verified) |
94.188.205.169 |
HARI SWAMI LLC |
Limited Liability Company |
2759 Mt Pleasant St, Burlington, IA 52601 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-12 |
BRANDON KELLY |
MARKWILLIAMSPRO@GMAIL.COM |
FRUIT HEIGHTS |
DAVIS |
UTAH |
MARK WILLIAMS |
GREG VANCAMP |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BRANDON KRLLY |
MARKWILLIAMSPRO@GMAIL.COM |
SELF |
FRUIT HEIGHTS |
DAVIS |
UTAH |
MARK WILLIAMS |
GREG VANCAMP |
Signed |
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 |
1648 |
2023-05-16 08:16 |
Anonymous (not verified) |
94.188.205.169 |
Hernandez Drywall |
Proprietorship |
2001 8th St Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-16 |
Gerardo Hernandez |
gerardohernandez56u@gmail.com |
Coralville |
Johnson |
Iowa |
Brad Bower |
Kirk Strucnk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerardo Hernandez |
gerardohernandez56u@gmail.com |
Self |
Coralville |
Johnson |
iowa |
Brad Bower |
Kirk Strunk |
Signed |
1656 |
2023-05-22 11:48 |
Anonymous (not verified) |
94.188.205.169 |
Cesar Arroyo |
Proprietorship |
2207 Lisa Drive, Webster City IA 50595 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-18 |
Cesar Arroyo |
office.seamlesspros@icloud.com |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar Arroyo |
office.seamlesspros@icloud.com |
Self |
Webster City |
Hamilton |
Iowa |
Jessica Knutson |
Keith Clabaugh |
Signed |
1706 |
2023-06-23 17:32 |
Anonymous (not verified) |
94.188.205.169 |
pro plumbing and heating llc |
Limited Liability Company |
109 w market st, po box 205 saint charles ia 50240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-23 |
lee douglas kearney |
ankenypro@gmail.com |
saint charles |
madison |
iowa |
sheila may kearney |
madison grace kearney |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
lee d kearney |
ankenypro@gmail.com |
owner |
saint charles |
madison |
iowa |
sheila may kearney |
madison grace kearney |
Signed |
1716 |
2023-06-29 09:19 |
Anonymous (not verified) |
94.188.205.169 |
Christine wanjiru chege |
Limited Liability Company |
43994 w cowpath rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-29 |
Christine Chege |
christine@acuitystaffingagency.com |
Maricopa |
Pinal |
AZ |
Daniel Mwangi |
Anne Chege |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christine chege |
christine@acuitystaffingagency.com |
Owner |
Maricopa |
Pinal |
AZ |
Daniel Mwangi |
Anne Chege |
Signed |
1717 |
2023-06-29 11:42 |
Anonymous (not verified) |
94.188.205.169 |
POWDER COATING CENTER |
Limited Liability Company |
61 3RD ST NE HARTLEY IA 51346 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-28 |
MATT EMBREY |
MSEMBREY21@GMAIL.COM |
HARTLEY |
OBRIEN |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATT EMBREY |
MSEMBREY21@GMAIL.COM |
OWNER |
HARTLEY |
OBRIEN |
IOWA |
TAMI KLEIN |
JENNIFER YOUNGWIRTH |
Signed |
1722 |
2023-07-06 10:57 |
Anonymous (not verified) |
94.188.205.169 |
Brother’s Handyman Services LLC |
Proprietorship |
1270 A Avenue, Marion, IA 52302, 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. |
2023-07-06 |
Tyler Dahl |
handybros39@gmail.com |
Marion, IA |
Linn County |
Iowa |
Jordan Nisiewicz |
Charles Woods |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City, MO |
Johnson |
Missouri |
Charles Woods |
Jordan Loyd |
Signed |
1460 |
2023-02-16 12:36 |
Anonymous (not verified) |
94.188.205.174 |
Certified Septic Service |
Proprietorship |
2121 Rodeo ave monroe iowa 50170 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-16 |
Justin Rozendaal |
jusroz12@gmail.com |
Monroe |
Jasper |
Iowa |
Justin Rozendaal |
Miranda Rozendaal |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin Rozendaal |
certifiedseptic@gmail.com |
Self |
Monroe |
Jasper |
Iowa |
Justin Rozendaal |
Miranda Rozendaal |
Signed |
1476 |
2023-02-22 12:23 |
Anonymous (not verified) |
94.188.205.174 |
KARL INGWERSEN |
Proprietorship |
2716 FRANCIS SITES DR SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-22 |
KARL INGWERSEN |
KARL58INGWERSEN@GMAIL.COM |
SPIRIT LAKE |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
KARL INGWERSEN |
KARL58INGWERSEN@GMAIL.COM |
SELF |
SPIRIT LAKE |
DICKSINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1525 |
2023-03-20 15:28 |
Anonymous (not verified) |
94.188.205.174 |
Valentin Saucedo |
Proprietorship |
1811 W 5th St, Sioux City, IA 51103 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-20 |
Valentin Saucedo |
sauceds20@gmail.com |
Sioux City |
Woodbury |
IA |
Jacob Goodin |
Kevin Small |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Valentin Saucedo |
sauceds20@gmail.com |
Sole Prop |
Sioux City |
Woodbury |
IA |
Jacob Goodin |
Kevin Small |
Signed |
1532 |
2023-03-24 18:05 |
Anonymous (not verified) |
94.188.205.174 |
Crafty Dome LLC |
Limited Liability Company |
3524 Stonebridge Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-24 |
Susan Bernau |
craftydome@yahoo.com |
West Des Moines |
Polk |
Iowa |
George Cummins |
Linda Green |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Susan Bernau |
craftydome@yahoo.com |
owner |
3524 Stonebridge Rd |
Polk |
Iowa |
George Cummins |
Linda Green |
Signed |
1536 |
2023-03-27 10:47 |
Anonymous (not verified) |
94.188.205.174 |
Cecile C Knipp |
Limited Liability Company |
1418 Oakcrest Dr., Waterloo, IA 50701 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-27 |
Cecile C Knipp |
ceilknipp@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Monica Robbins |
Anne Betts |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cecile C Knipp |
christinaknipp@aol.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Monica Robbins |
Anne Betts |
Signed |
1541 |
2023-03-29 11:21 |
Anonymous (not verified) |
94.188.205.174 |
Juilfs Trucking |
Proprietorship |
709 S Geneva St., P.O. Box 252 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-29 |
Terry Juilfs |
sarah_burke7274@hotmail.com |
Pomeroy |
IA |
United States |
Lorie Gerdes |
Kerstin Lyon |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Terry Juilfs |
sarah_burke7274@hotmail.com |
Myself |
Pomeroy |
IA |
United States |
Lorie Gerdes |
Kerstin Lyon |
Signed |
1560 |
2023-04-07 11:47 |
Anonymous (not verified) |
94.188.205.174 |
Art Deco Tile and Stone |
Limited Liability Company |
4615 94th Pl Urbandale, IA 50322 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-07 |
Jasmin Musinovic |
edin@artdecotileandstone.com |
Urbandale |
Polk |
Iowa |
Rick Wyant |
Todd Wyant |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jasmin Musinovic |
edin@artdecotileandstone.com |
Self |
Urbandale |
Polk |
Iowa |
Rick Wyant |
Todd Wyant |
Signed |
1562 |
2023-04-10 07:43 |
Anonymous (not verified) |
94.188.205.174 |
JB Concrete and Construction |
Limited Liability Company |
306 1st Ave N.W Dayton Ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-10 |
JaredBerglund |
jaredberglund71@gmail.com |
Dayton |
Webster |
Iowa |
Travis Sonksen |
Chase Haman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JaredBerglund |
jaredberglund71@gmail.com |
Owner |
Dayton |
Webster |
Iowa |
Travis Sonksen |
Chase Haman |
Signed |
1564 |
2023-04-11 09:15 |
Anonymous (not verified) |
94.188.205.174 |
Darryl Kinnard |
Proprietorship |
60 Miller Avenue Southwest #13, Cedar Rapids, IA 52404, United States |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-11 |
Darryl Kinnard |
darryl186d@icloud.com |
Cedar Rapids |
Linn County |
Iowa |
Jordan Nisiewicz |
Jordan Loyd |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
Missouri |
Jordan Loyd |
Robert Snyder |
Signed |
1578 |
2023-04-17 15:33 |
Anonymous (not verified) |
94.188.205.174 |
Spark Train Express LLC |
Limited Liability Company |
16877 500th St, Pocahontas, IA 50574 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-17 |
Austin Sparks |
sparksaustin.11@gmail.com |
Pocahontas |
Pocahontas |
Iowa |
Stephanie Webbink |
Christian Lynch |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Austin Sparks |
sparksaustin.11@gmail.com |
Owner |
Pocahontas |
Pocahontas |
Iowa |
Stephanie Webbink |
Christian Lynch |
Signed |
1588 |
2023-04-19 11:04 |
Anonymous (not verified) |
94.188.205.174 |
Peters Tree Service |
Proprietorship |
205 Melrose St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-19 |
Timothy F Peters |
tim_peters1@hotmail.com |
Wall Lake |
Sac |
Iowa |
Bruce Paysen |
Roberta Paysen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Timothy F Peters |
tim_peters1@hotmail.com |
Self |
Wall Lake |
Sac |
Iowa |
Brace Paysen |
Roberta Paysen |
Signed |
1596 |
2023-04-24 15:48 |
Anonymous (not verified) |
94.188.205.174 |
Loyal Transport INC |
Proprietorship |
1987 Middle Calmar Road, 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. |
2022-02-01 |
Lloyd Bjergum |
aryan1950@hotmail.com |
Decorah, IA |
Winneshiek |
Iowa |
Allen Monroe |
Amy Ryan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lloyd Bjergum |
aryan1950@hotmail.com |
Self |
Decorah, |
Winneshiek |
Iowa |
Allen Monroe |
Amy Ryan |
Signed |
1598 |
2023-04-25 07:02 |
Anonymous (not verified) |
94.188.205.174 |
Johnny Pommer |
Limited Liability Company |
4125, E 30th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-25 |
Johnny Pommer |
bravojohnny@me.com |
Des Moines |
United states |
IA |
Johnny Pommer |
Kimberly pommer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Johnny Pommer |
bravojohnny@me.com |
Owner |
Des Moines |
United States |
IA |
Johnny Pommer |
Kimberly pommer |
Signed |
1603 |
2023-04-25 20:42 |
Anonymous (not verified) |
94.188.205.174 |
Nursepro Staffing Agency |
Limited Liability Company |
8450 Hickman Rd suite A2 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2023-04-25 |
Teresiah muchemi |
nurseproagency@gmail.com |
desmoines |
polk |
iowa |
Teresiah Muchemi |
John Waweru |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Teresiah Muchemi |
nurseproagency@gmail.com |
Owner |
desmoines |
Polk |
iowa |
Teresiah Muchemi |
John Waweru |
Signed |
1622 |
2023-05-01 16:05 |
Anonymous (not verified) |
94.188.205.174 |
Danny Shineflew |
Proprietorship |
103th 10street West Des Moines |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-01 |
Danny Shineflew |
dannyshineflew@gmail.com |
West Des Moines |
Polk |
Iowa |
Tony Ekman |
Dustin Hogan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Danny Shineflew |
dannyshineflew@gmail.com |
self |
West Des Moines |
Polk |
Iowa |
Tony Ekman |
Dustin Hogan |
Signed |
1634 |
2023-05-10 07:21 |
Anonymous (not verified) |
94.188.205.174 |
KS Drywall |
Proprietorship |
404 E Jayne Street Lone Tree, IA 52755 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-05-10 |
Kirk Strunk |
kirkstrunk@gmail.com |
Lone Tree |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kirk Strunk |
kirkstrunk@gmail.com |
Self |
Lone Tree |
Johnson |
Iowa |
Chris Hay |
Brad Bower |
Signed |
1679 |
2023-06-06 08:27 |
Anonymous (not verified) |
94.188.205.174 |
Remys Drywall LLC |
Proprietorship |
42 Hoover Blvd West Branch, IA 52358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-06 |
Remigio M Juan |
remmateojuan1997@gmail.com |
West Branch |
Cedar |
IA |
Brad Bower |
Chris Hay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Remigio M Juan |
remmateojuan1997@gmail.com |
Self |
West Branch |
Cedar |
IA |
Brad Bower |
Chris Hay |
Signed |
1682 |
2023-06-08 17:55 |
Anonymous (not verified) |
94.188.205.174 |
Jared hoffman |
Proprietorship |
22429 250th st carroll IA 5140q |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-06 |
Jared Hoffman |
jhoffman@live.com |
Carroll |
Carroll |
Iowa |
Jeff dentlinger |
Brian babb |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Hoffman |
jhoffman@live.com |
Self |
Carroll |
Carroll |
Iowa |
Jeff dentlinger |
Brian babb |
Signed |
1691 |
2023-06-14 19:20 |
Anonymous (not verified) |
94.188.205.174 |
Amazing Painting LLC |
Limited Liability Company |
1301 Boyd Street, 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. |
2023-06-14 |
Evan Michael Regenwether |
Evan@amazingpaintingia.com |
Des Moines |
Polk |
Iowa |
Austin Matthew Regenwether |
Abby Marie Regenwether |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Evan Michael Regenwether |
evan@amaingpaintingia.com |
Owner |
Des Moines |
Polk |
Iowa |
Austin Matthew Regenwether |
Abby Regenwether |
Signed |