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 |
424 |
2021-03-05 15:56 |
Anonymous (not verified) |
65.103.82.36 |
Guardian Angel Specialty Cleaners |
Proprietorship |
1018 W 14th Street, Davenport IA 52804 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-18 |
Leesa Monson |
LMonson@gmail.com |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Leesa Monson |
LMonson@gmail.com |
Self |
Davenport |
Scott |
Iowa |
Dawn Tague |
Eric Johnson |
Signed |
158 |
2020-05-18 13:58 |
Anonymous (not verified) |
108.59.100.21 |
LNM Truck & Trailer Repair LLC |
Limited Liability Company |
902 Rossville Rd, Waukon, IA 52172 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2020-05-18 |
Matthew Hawkins |
lnmtruckandtrailerrepair@gmail.com |
Waterville |
Allamakee |
IA |
Jane M Regan |
Chelsea Whalen |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Matthew Hawkins |
lnmtruckandtrailerrepair@gmail.com |
Owner |
Waterville |
Allamakee |
IA |
Jane M Regan |
Chelsea Whalen |
Signed |
1043 |
2022-04-12 18:20 |
Anonymous (not verified) |
66.129.218.53 |
DON'S LOCK & SAFE LLC |
Proprietorship |
4223 YVETTE ST SUITE 101, IOWA CITY, IA 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-12 |
BRIAN E LOUGH |
LOLOCK@LIVE.COM |
NORTH LIBERTY |
JOHNSON |
IOWA |
WILLIAM H CRILE |
KELLI L SCOTT |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BRIAN E LOUGH |
LOLOCK@LIVE.COM |
OWNER |
NORTH LIBERTY |
JOHNSON |
IA |
WILLIAM H CRILE |
KELLI L SCOTT |
Signed |
1807 |
2023-08-17 12:45 |
Anonymous (not verified) |
94.188.205.175 |
LONE STAR ROOFING, LLC |
Limited Liability Company |
4021 WINDSOR CT DES MOINES, IA 50320 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-17 |
RAQUEL B DIAZ MENENDEZ |
LONE.STAR.ROOFING76@GMAIL.COM |
DES MOINES |
USA |
IOWA |
LILIANA SANCHEZ |
RENE ALEXANDER VELASCO |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
LONE STAR ROOFING, LLC |
LONE.STAR.ROOFING76@GMAIL.COM |
MEMBER OWNER |
DES MOINES |
USA |
IOWA |
LILIANA SANCHEZ |
RENE ALEXANDER VELASCO |
Signed |
1708 |
2023-06-25 15:10 |
Anonymous (not verified) |
94.188.207.228 |
Lopez concrete |
Limited Liability Company |
2009 otley 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. |
2023-06-25 |
Erick Lopez |
lopez1concrete@gmail.com |
Perry |
Dallas |
IA |
Ever tobar. |
Elba alejandro |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erick lopez |
lopez1concreto@gmail.com |
Owner |
Perry |
Dallas |
IA |
Ever tobar |
Elba alejandro |
Signed |
631 |
2021-09-02 22:46 |
Anonymous (not verified) |
173.23.144.4 |
Lopez Framing LLC |
Limited Liability Company |
566 walker st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-02 |
Diana A Garcia Lopez |
lopezframing0702@gmail.com |
Des moines |
Polk |
Iowa |
Marlon Lopez |
Jennifer Reyes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Diana A Garcia Lopez |
lopezframing0702@gmail.com |
Owner |
Des moines |
Polk |
Iowa |
Marlon Lopez |
Jennifer Reyes |
Signed |
1906 |
2023-11-14 13:47 |
Anonymous (not verified) |
94.188.207.223 |
HRBC Plus |
Limited Liability Company |
249 SOLOMIA CT, Peosta, IA 52068 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-11 |
Lori S Stewart |
lori@hrbcplus.com |
PEOSTA |
Dubuque |
United States |
Mark R Stewart |
Danielle M Leibfried |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori Stewart |
lori@hrbcplus.com |
Self |
Peosta |
Dubuque |
United States |
Mark R Stewart |
Danielle M Peterson |
Signed |
2014 |
2024-01-31 15:17 |
Anonymous (not verified) |
94.188.205.174 |
Aspen Ridge LLC |
Limited Liability Company |
1404 G 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. |
2023-05-10 |
Lori McKusker |
lori@mckuskerelectric.com |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lori McKusker |
jeff@mckuskerelectric.com |
Self |
Mead |
Weld |
Colorado |
Karly Kovar |
Jacob McKusker |
Signed |
998 |
2022-03-23 08:34 |
Anonymous (not verified) |
104.201.100.158 |
L Peterson Insurance, LLC |
Limited Liability Company |
603 Pleasant View Drive Des Moines, IA 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-23 |
Lucas Peterson |
lpeterson@phillipsstafford.com |
Des Moines |
Polk |
Iowa |
Luke Van Roekel |
Sam Debartolo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucas Peterson |
lpeterson@phillipsstafford.com |
Owner |
Des Moines |
Polk |
Iowa |
Luke Van Roekel |
Sam Debartolo |
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 |
1215 |
2022-07-20 13:43 |
Anonymous (not verified) |
173.21.133.45 |
Ottumwa mow & snow LLC |
Limited Liability Company |
11443 Bladensburg Rd. Ottumwa IA 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-20 |
Lucia A Hughes |
lucyh68313@gmail.com |
Ottumwa |
Wapello |
Iowa |
Katy Knott |
Doug Knott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RJ Hallman |
rjhallman@fedins.com |
Insurance |
Owatonna |
Steele |
Minnesota |
Katy Knott |
Doug Knott |
Signed |
1599 |
2023-04-25 14:38 |
Anonymous (not verified) |
94.188.207.229 |
luis contreras |
Proprietorship |
433 8th ave sw |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-25 |
luis contreras |
luisayala781@gmail.com |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
luis contreras |
luisayala781@gmail.com |
N/A |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
1597 |
2023-04-24 16:03 |
Anonymous (not verified) |
94.188.207.224 |
4 Iowa Construction LLC |
Limited Liability Company |
1750 Lyon St Des Moines, IA 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-24 |
Luis E Cancino Mireles |
luiscancino55@gmail.com |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis E Cancino Mireles |
luiscancino55@gmail.com |
self / 100% owner / manager of the LLC |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
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 |
1579 |
2023-04-17 17:00 |
Anonymous (not verified) |
94.188.205.177 |
Home provisions siding LLC |
Limited Liability Company |
1816 Francis avenue apt 1 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-17 |
Luis Alberto Ramirez Mendez |
luisramirez4308@icloud.com |
Desmoines |
Polk |
Iowa |
Alexandra Gomez-Benitez |
Marcedez ramirez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis Alberto Ramirez Mendez |
luisramirez4308@icloud.com |
None |
Des Moines |
Polk |
Iowa |
Alexandra Gomez-Benitez |
Marcedez Roxana Ramirez |
Signed |
1776 |
2023-08-03 13:51 |
Anonymous (not verified) |
94.188.207.224 |
Lucas Adam Peterson |
Proprietorship |
2833 SE 68th St 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. |
2023-08-03 |
Lucas Adam Peterson |
Luke.Peterson.mzub@gmail.com |
Pleasant Hill |
POLK |
IOWA |
Sarah Peterson |
Samuel Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Lucas Adam Peterson |
Luke.Peterson.mzub@gmail.com |
Self |
PLEASANT HILL |
IA |
United States |
Sarah Peterson |
Samuel Peterson |
Signed |
1063 |
2022-04-21 08:23 |
Anonymous (not verified) |
207.155.112.81 |
Prudenterra, LLC |
Limited Liability Company |
65584 260th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-04-21 |
Luke Robert Gran |
luke@prudenterra.com |
Nevada |
Story |
Iowa |
Michael Joseph Coverdale |
Judy Rae Coverdale |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Luke Robert Gran |
luke@prudenterra.com |
Self |
Nevada |
Story |
Iowa |
Michael Joseph Coverdale |
Judy Rae Coverdale |
Signed |
1898 |
2023-11-09 09:56 |
Anonymous (not verified) |
94.188.207.227 |
RC Restoration LLC |
Limited Liability Company |
991 June Drive, Dubuque, IA 52003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-09 |
Luke Hoffmann |
luke@rentcube.com |
Dubuque |
Dubuque |
Iowa |
Randi Taylor |
Carla Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Hoffman |
luke@rentcube.com |
Owner |
Dubuque |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
1449 |
2023-02-11 10:37 |
Anonymous (not verified) |
94.188.207.227 |
Luxury Home Improvements |
Limited Liability Company |
4117 Boyd st Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-11 |
Luis A Hernandez |
luxuryhomes.iowa@gmail.com |
Des Moines |
Polk |
Iowa |
Maria T Lopez |
Josmar Hernandez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luis A Hernandez |
luxuryhomes.iowa@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Maria T Lopez |
Josmar Hernandez |
Signed |
999 |
2022-03-23 08:39 |
Anonymous (not verified) |
104.201.100.158 |
Van Roekel Insurance |
Limited Liability Company |
25919 330th Ct, Adel Iowa 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-23 |
Luke Jon Van Roekel |
Lvanroekel@phillipsstafford.com |
Adel |
Dallas |
Iowa |
Megan Van Roekel |
Luke Peterson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Luke Jon Van Roekel |
lvanroekel@phillipsstafford.com |
Owner |
Adel |
IA |
United States |
Megan Van Roekel |
Luke Peterson |
Signed |
1646 |
2023-05-15 13:13 |
Anonymous (not verified) |
94.188.207.224 |
Aspen leaf Painting |
Limited Liability Company |
3846 Lower Beaver 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. |
2023-05-15 |
Michael Patrick Vajda |
m.p.vajda@gmail.com |
Des Moines |
Polk |
IA |
Patrick Vajda |
Mike Vajda |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Vajda |
m.p.vajda@gmail.com |
Self |
Des Moines |
Polk |
IA |
Mike Vajda |
Michael Vajda |
Signed |
1926 |
2023-11-29 10:45 |
Anonymous (not verified) |
94.188.207.224 |
M&M Janitorial LLC |
Limited Liability Company |
243 28th St Dr 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. |
2023-11-29 |
Mackenzie Willits |
mackenziewillits@gmail.com |
Cedar Rapids |
Linn |
United States |
Fransisco ruiz |
Alexander ruiz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meyling willits |
mackenziewillits@gmail.com |
Owner |
cedar rapids |
Linn |
United States |
Alexander ruiz |
Francisco ruiz |
Signed |
524 |
2021-05-17 22:41 |
Anonymous (not verified) |
166.181.84.162 |
Laven Construction LLC |
Limited Liability Company |
4935 NE 78th Ave Bondurant, Iowa 50035 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-17 |
MacKale Laven |
maclaven@gmail.com |
Bondurant |
Polk |
Iowa |
John Smith |
Cameron Thede |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MacKale Laven |
maclaven@gmail.com |
Owner |
Bondurant |
Polk |
Iowa |
Cameron Thede |
John Smith |
Signed |
449 |
2021-03-25 10:53 |
Anonymous (not verified) |
174.198.73.94 |
A&F Painting llc |
Limited Liability Company |
411 E Dunham ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-25 |
Miguel Afanador Olguin |
mafanador02@gmail.com |
Des Moines |
Polk |
Iowa |
Alfonzo Afanador |
Noemi Afanador |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Afanador Olguin |
mafanador02@gmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Alfonzo Alfanador |
Noemi Alfanador |
Signed |
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 |
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 |
1875 |
2023-10-23 11:34 |
Anonymous (not verified) |
94.188.205.176 |
Makers Blinds LLC |
Limited Liability Company |
3220 44Th St Des Moines, IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-23 |
Ryan Seiler |
makersblinds@gmail.com |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ryan Seiler |
makersblinds@gmail.com |
Manager |
Des Moines |
Polk |
Iowa |
Jon Buller |
Terry Miles |
Signed |
534 |
2021-06-04 12:47 |
Anonymous (not verified) |
192.119.129.187 |
KMA Communications, LLC |
Limited Liability Company |
435 croston rd. Stockport, OH 43787 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-04 |
Matthew Razen Alsup |
malsupbrgi@gmail.com |
Stockport |
Morgan |
Ohio |
Stephen Alsup |
Nancy Alsup |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Razen Alsup |
malsupbrgi@gmail.com |
Same person |
Stockport |
Morgan |
Ohio |
Stephen Alsup |
Nancy Alsup |
Signed |
1768 |
2023-07-29 11:10 |
Anonymous (not verified) |
94.188.207.223 |
Makana Industries LLC |
Limited Liability Company |
1800 Grand Ave #352, West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-29 |
Matthew Akana |
mandiremod515@gmail.com |
West Des Moines |
Polk |
Iowa |
Catherine Sobrado |
James Fowler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rocket Lawyer Corporate Services LLC |
mandiremod515@gmail.com |
Registered agent |
Des Moines |
Polk |
Iowa |
Catherine Sobrado |
James Fowler |
Signed |
1961 |
2023-12-16 12:22 |
Anonymous (not verified) |
94.188.207.228 |
Randy Hove |
Proprietorship |
2376 370th St. Jewell. Iowa. 50130 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-14 |
Randy Gordon Hove |
mandrhove@gmail.com |
Jewell |
Hamilton |
Iowa |
Ryan Drzycimski |
Casey Westling |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Randy |
mandrhove@gmail.com |
Same |
Same |
Same |
Same |
Same |
Same |
Signed |
2043 |
2024-02-13 13:38 |
Anonymous (not verified) |
94.188.207.226 |
mannys handyman services |
Limited Liability Company |
3084 120th st cumming ia 50061 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-13 |
manuel v banegas |
mannyshandymanservices.ia@gmail.com |
cumming |
3084 120th st |
iowa |
Adam Boge |
Lance Webster |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
manuel v banegas |
mannyshandymanservices.ia@gmail.com |
self employeed |
Cumming |
Madison |
Iowa |
Adam Boge |
Lance Webster |
Signed |
777 |
2021-12-04 10:20 |
Anonymous (not verified) |
107.77.161.58 |
Martinez Painting |
Proprietorship |
3219 bowdoin st desmoines ia 50316 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-04 |
Martinez Manuel |
Manuelitogladis29@gmail.com |
Desmoines |
Polk |
Iowa |
Yasco adilovic |
Samir radinovick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martinez Manuel |
Manuelitogladis29@gmail.com |
Owner |
Desmoines |
Polk |
Iowa |
Yasco adilovic |
Samir radinovic |
Signed |
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 |
2099 |
2024-03-15 18:50 |
Anonymous (not verified) |
94.188.205.174 |
OMG Bros, LLC |
Limited Liability Partnership |
404 Ivanhoe Rd, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2024-03-15 |
Marco Antonio Gaytan |
marcogaytan77@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Kaden Lyle |
Arayely Vazquez |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Tristan Anthony Siebrands |
omgservices@omgbros.org |
Partner |
Waterloo |
Black Hawk |
Iowa |
Kaden Lyle |
Arayely Vazquez |
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 |
1220 |
2022-07-21 13:12 |
Anonymous (not verified) |
172.58.83.160 |
Ottumwa mow & snow LLC |
Limited Liability Company |
11443 Bladensburg Rd. Ottumwa IA 52501 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
María Duarte |
mariacabrera515@icloud.com |
Ottumwa |
Wapello |
Iowa |
Katy Knott |
Doug Knott |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
RJ Hallman |
rjhallman@fedins.com |
Insurance |
Owatonna |
Steele |
Minnesota |
Katy Knott |
Doug Knott |
Signed |
938 |
2022-02-25 15:21 |
Anonymous (not verified) |
174.215.247.215 |
Maria castillo |
Limited Liability Company |
2200 scott blvd #90 iowa city iowa 52240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-25 |
Maria evangelina castillo moreno |
mariacastillo852@yahoo.com |
Iowa city |
Jonhson |
Iowa |
Maria castillo |
Emilio Castillo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maria evangelina castillo moreno |
mariacastillo852@yahoo.vom |
Work |
Iowa city |
Johnson |
Iowa |
Maria castillo |
Emilio Castillo |
Signed |
405 |
2021-02-17 11:04 |
Anonymous (not verified) |
104.201.67.178 |
CYE Painting |
Limited Liability Company |
5202 SE 31st 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. |
2021-02-17 |
CYE Painting |
marilopez9657@yahoo.com |
Des Moines |
Polk |
Iowa |
Maricela Lopez |
Cruz Cabrera |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maricela Lopez |
marilopez9657@yahoo.com |
N/a |
Des Moines |
Polk |
IA |
Maricela Lopez |
Cruz Cabrera |
Signed |
669 |
2021-10-13 08:24 |
Anonymous (not verified) |
64.191.11.62 |
E360 Building Company, Inc. |
Proprietorship |
PO Box 363, Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-13 |
Mark Miller |
mark@e360buildingco.com |
Cedar Falls |
Black Hawk |
Iowa |
Laetyn Miller |
Grant Williamson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Miller |
markm@cfu.net |
Self |
Cedar Falls |
Black Hawk |
Iowa |
Laetyn Miller |
Grant Williamson |
Signed |
1317 |
2022-09-21 15:04 |
Anonymous (not verified) |
184.81.198.17 |
Mark Jagnow |
Proprietorship |
2174 Rohret Rd SW Oxford IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-21 |
Mark Allen Jagnow |
Mark@Jagnow.com |
Oxford |
Johnson |
Iowa |
Catherine Louise Nelson |
Joseph Roger Titone |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Allen Jagnow |
Mark@jagnow.com |
self |
Oxford |
Johnson |
Iowa |
Catherine Louise Nelson |
Joseph Roger Titone |
Signed |
1296 |
2022-09-07 08:55 |
Anonymous (not verified) |
67.55.155.204 |
Kevin Utterback II |
Proprietorship |
801 E Ave W. Oskaloosa, Iowa 52577 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-07 |
Kevin Utterback II |
mark@johnsoninsurancesales.com |
Oskaloosa |
Iowa |
Iowa |
Scott Miller |
Kim Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Utterback |
mark@johnsoninsurancesales.com |
owner of company |
Oskaloosa |
Iowa |
Iowa |
Scott Miller |
Kim Miller |
Signed |
880 |
2022-02-01 14:05 |
Anonymous (not verified) |
207.45.88.5 |
Known Labs LLC |
Limited Liability Partnership |
8350 Ep True Pkwy, UNIT 1201 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained 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 |
Marcus Antonio Smith |
mark@knownlabs.net |
West Des Moines |
Dallas |
IA |
Dan Morgan III |
Amber Smith |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marcus Antonio Smith |
mark@knownlabs.net |
Owner |
West Des Moines |
IA |
IA |
Daniel Morgan III |
Amber Smith |
Signed |
1899 |
2023-11-09 16:55 |
Anonymous (not verified) |
94.188.207.227 |
Factory Services |
Limited Liability Company |
2444 Elm Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-09 |
Mark Farrell |
markfa12@yahoo.com |
Fort Dodge |
Webster |
Iowa |
Heather Farrell |
Karson Farrell |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Farrell |
markfa12@yahoo.com |
Owner |
Fort Dodge |
Webster |
Iowa |
Heather Farrell |
Karson12 |
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 |
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 |
210 |
2020-07-20 13:28 |
Anonymous (not verified) |
75.162.95.97 |
RM construction |
Proprietorship |
65 SE 5TH STREET APT 4 DES MOINES IA . 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-20 |
Rafael Marquez |
marquezrafael1@outlook.com |
Des Moines |
Polk IOWA |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rafael Marquez |
marquezrafael1@outlook.com |
owner |
Des Moines |
Polk |
IOWA |
Richard Yanez |
Francisco Garcia |
Signed |
1224 |
2022-07-23 14:14 |
Anonymous (not verified) |
69.57.205.10 |
Robert W. Cantrell |
Proprietorship |
845 East Redwood Circle, Hanford, CA 93230 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-23 |
Robert Wescott Cantrell |
marquisaviationinc@yahoo.com |
Hanford |
Kings |
CA |
Shirley J. Loney |
Joel L. Meyer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Westcott Cantrell |
marquisaviationinc@yahoo.com |
proprietor |
Hanford |
Kings |
CA |
Shirley J. Loney |
Joel L. Meyer |
Signed |
1793 |
2023-08-09 15:23 |
Anonymous (not verified) |
94.188.205.174 |
Cesar estuardo marroquin gonzalez |
Proprietorship |
1212 David st waterloo iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-09 |
Cesar estuardo marroquin gonzalez |
marroquincesar1788@gmail.com |
1212 David st waterloo iowa |
Black haw |
Iowa |
Sonia Gomez |
Sonia Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Cesar estuardo marroquin gonzalez |
marroquincesar1788@gmail.com |
Patrón |
1212 David st waterloo iowa |
Black hawn |
Iowa |
Sonia Gomez |
Sonia Gomez |
Signed |
2045 |
2024-02-15 10:26 |
Anonymous (not verified) |
94.188.207.227 |
Francesco Martinez |
Proprietorship |
403th 7th Ave NW Clarion IA 50525 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-15 |
Francesco Martinez |
Martinexfrancesco99@gmail.com |
Clarion |
Wright |
Iowa |
Jason W Helmers |
Josh W Helmers |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Francesco Martinez |
martinezfrancesco99@gmail.com |
Employer |
Clarion |
Wright |
Iowa |
Jason W Helmers |
Josh W Helmers |
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 |
1600 |
2023-04-25 14:38 |
Anonymous (not verified) |
94.188.207.223 |
martin garcia |
Proprietorship |
219 austin st sw cedar rapids iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-04-25 |
martin garcia ayala |
martingarcia2100@gmail.com |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
martin garcia ayala |
martingarcia2100@gmail.com |
na |
cedar rapids |
linn |
iowa |
Ryan Klein |
Karina Jacobson |
Signed |
536 |
2021-06-07 11:01 |
Anonymous (not verified) |
205.221.255.62 |
Mark Lile |
Limited Liability Partnership |
PO Box 36411 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-06-07 |
Martin Luverne Humphrey Jr |
martinhumphreu@gmail.com |
Des Moines |
Polk |
Iowa |
Jaimi Humphrey |
George Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Lile |
Mark@ultimateautowash.com |
Employer |
Des Moines |
Polk |
Iowa |
Jaimi Humphrey |
George Porter |
Signed |
581 |
2021-07-22 14:29 |
Anonymous (not verified) |
205.221.255.62 |
MartinHumphrey |
Limited Liability Company |
Cummins Rd. Apt 202 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-22 |
Martin Luverne Humphrey Jr. |
martinhumphreu@gmail.com |
Des Moines |
Polk |
Ioea |
George Porter |
Gerald Lund |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Martin Luverne Humphrey Jr |
martinhumphreu@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
George Porter |
Gerald Lund |
Signed |
2130 |
2024-04-02 09:11 |
Anonymous (not verified) |
94.188.207.229 |
Caliz Stone Services LLC |
Limited Liability Company |
1715 E 21st St, Des Moines IA 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-02 |
Marvin Lopez |
marvincaliz843@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Marvin Lopez |
marvincaliz843@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
473 |
2021-04-13 11:26 |
Anonymous (not verified) |
65.103.82.36 |
Quality Renovation |
Proprietorship |
1406 25th st Moline IL 61265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-06-21 |
Clarence Marvin Skipton |
marvinthemartien77@gmail.com |
Buffalo |
Scott |
IA |
Jennifer Skipton |
Rose mary Skipton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Clarence Marvin Skipton |
marvinthemartien77@gmail.com |
Owner |
Moline |
Rock Island |
IL |
Jennifer skipton |
rose Skipton |
Signed |
1390 |
2022-12-12 10:27 |
Anonymous (not verified) |
97.125.170.79 |
Norwalk Cleaning Servicesw |
Limited Liability Company |
520 W High Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-12-12 |
Jacob Hibbert |
Maryhib@icloud.com |
Norwalk |
IA |
United States |
Kyle Grandstaff |
Nicole Nichols |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacob Hibbert |
maryhib@icloud.com |
Self |
Norwalk |
Warren |
United States |
Kyle Grandstaff |
Nicole Nichols |
Signed |
1014 |
2022-03-28 16:33 |
Anonymous (not verified) |
76.102.203.170 |
Self - Maryssa Wanlass |
Proprietorship |
871 Wood St. Oakland CA 94607 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-01 |
Maryssa Wanlass |
maryssa.wanlass@alli-center.com |
Oakland |
Alameda |
California |
Mark Vashro |
Don Naughton |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maryssa Wanlass |
maryssa.wanlass@alli-center.com |
Self |
Oakland |
Alameda |
California |
Mark Vashro |
Don Naughton |
Signed |
1328 |
2022-10-07 22:45 |
Anonymous (not verified) |
50.82.178.112 |
Compass Commercial Services LLC |
Limited Liability Company |
1950 Boyson road, Hiawatha, Ia 52233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-07 |
Patrick Roland |
mastershineservices@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Aubrey Hantz |
Brenna Trinkle |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Blake Fortanini |
bfontanini@compassbuilt.com |
Project Manager |
Hiawatha |
Linn |
Iowa |
Aubrey Hantz |
Brenna Trinkle |
Signed |
2197 |
2024-05-02 09:30 |
Anonymous (not verified) |
94.188.207.229 |
Melvin Osorio |
Proprietorship |
3848 E 14th St Trlr 78, 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. |
2024-05-02 |
Melvin Osorio |
matamorosana56@gmail.com |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melvin Osorio |
matamorosana56@gmail.com |
Self |
Des Moines |
Polk |
Iowa |
Fabiola Palomares |
Nathan Miller |
Signed |
2012 |
2024-01-31 10:38 |
Anonymous (not verified) |
94.188.207.228 |
Mathew Soulis |
Proprietorship |
618 Boston Drive, 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. |
2023-01-31 |
Mathew Soulis |
mathew.soulis@gmail.com |
Davenport |
Scott |
IA |
Jordan Nisiewicz |
Cody Dunbar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
JNisiewicz@leafhome.com |
Recruiter |
Kansas City |
Johnson |
MO |
Cody Dunbar |
Monica Acosta |
Signed |
377 |
2021-01-26 13:31 |
Anonymous (not verified) |
184.63.6.1 |
Matt Reynolds |
Proprietorship |
684 Cedar Valley Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-26 |
Matt Reynolds |
matt.reynolds0891@gmail.com |
Tipton |
Cedar |
Iowa |
Anna Miller |
Steve Miller |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Reynolds |
matt.reynolds0891@gmail.com |
Proprietorship |
Tipton |
Cedar |
Iowa |
Anna Miller |
Steve Miller |
Signed |
156 |
2020-05-13 20:37 |
Anonymous (not verified) |
216.106.236.82 |
MR Electric LLC |
Limited Liability Company |
1853 230st Inwood, IA 51240 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-05-13 |
Matthew Rozeboom |
matt.rozeboom@gmail.com |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Rozeboom |
matt.rozeboom@gmail.com |
Owner/President |
Inwood |
Lyon |
Iowa |
Rachel Schruers |
Caitlin Fluit |
Signed |
1238 |
2022-08-02 10:24 |
Anonymous (not verified) |
70.96.153.153 |
Matthew Smith |
Proprietorship |
2070 Golfview Ct, Marion, IA 52302 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-08-02 |
Matthew Smith |
matt.s@optionsexteriors.com |
Marion |
Linn |
Iowa |
Charlotte Rasmussen |
Aus |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Smith |
matt.s@optionsexteriors.com |
Self/Owner |
Marion |
Linn |
Iowa |
Charlotte Rasmussen |
Austin Miller |
Signed |
2081 |
2024-03-08 10:44 |
Anonymous (not verified) |
94.188.205.167 |
T & S Sandblasting and Painting LLC |
Limited Liability Company |
101 Clinton ST Corwith IA 50430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-08 |
Matthew Tindall |
matt.tindall83@gmail.com |
Corwith |
Hancock |
IA |
Wendy S Jensen |
Jason Bradley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Tindall |
matt.tindall83@gmail.com |
self |
Corwith |
Hancock |
IA |
Wendy S Jensen |
Jason Bradley |
Signed |
2082 |
2024-03-08 10:47 |
Anonymous (not verified) |
94.188.205.176 |
T & S Sandblastin and Painting LLC |
Limited Liability Company |
101 Clinton ST Corwith IA 50430 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-03-08 |
Robert Schissel |
matt.tindall83@gmail.com |
Corwith |
Hancock |
Iowa |
Wendy S Jensen |
Jason Bradley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Schissel |
matt.tindall83@gmail.com |
self |
Corwith |
Hancock |
Iowa |
Wendy S Jensen |
Jason Bradley |
Signed |
1463 |
2023-02-17 14:24 |
Anonymous (not verified) |
94.188.207.224 |
Matt Evans |
Limited Liability Company |
508 53rd Place West Des Moines, IA 50266 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-17 |
Matthew Evans |
matt@bigroofing515.com |
West Des Moines |
Polk |
Iowa |
Steve Bieghler |
Matt Evans |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Evans |
matt@bigroofing515.com |
Self |
West Des Moines |
Polk |
Iowa |
Steve Bieghler |
Matt Evans |
Signed |
514 |
2021-05-11 13:16 |
Anonymous (not verified) |
173.31.147.225 |
RUTHVEN ROCKS LLC |
Limited Liability Company |
1205 ROLLING ST RUTHVEN IOWA 51358 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-11 |
MATT CACEK |
MATT@RUTHVENROCKS.COM |
MILFORD |
DICKINSON |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATT CACEK |
joel@walkerinsuranceia.com |
MEMBER |
MILFORD |
PALO ALTO |
IOWA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
1465 |
2023-02-17 15:05 |
Anonymous (not verified) |
94.188.207.228 |
Big roofing |
Proprietorship |
114 sw 58th 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. |
2023-02-17 |
David Christiansen |
Mattc@bigroofing515.com |
Des moines |
Polk |
IA |
STEVE BIEGHLER |
Jordan walkup |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt christiansen |
Mattc@bigroofing515.com |
Self |
Des moines |
County |
Ia |
Steve bieghler |
Jordan walkup |
Signed |
1051 |
2022-04-14 17:56 |
Anonymous (not verified) |
199.59.236.46 |
Triple M Welding |
Proprietorship |
407 4th St Sw |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Matthew Gibson |
matthew.gibson02003@gmail.com |
Independence |
Iowa |
Iowa |
Brandon Keener |
Cody Laughlin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Gibson |
matthew.gibson02003@gmail.com |
Owner |
Independence |
Iowa |
Iowa |
Brandon Keener |
Cody Laughlin |
Signed |
55 |
2020-02-07 15:14 |
Anonymous (not verified) |
204.153.176.73 |
J*M Fuels, LLC |
Limited Liability Company |
600 W Bremer Avenue, Waverly IA 50677 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-07 |
Matt Johnson |
mattjohnson7555@gmail.com |
Jackson TWP |
Butler |
Iowa |
Ty Burke |
Lori Frerichs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tylor Burke |
tburke@acceladvantage.com |
Agent |
Waverly |
IA |
United States |
Tony Pollastrini |
Lori Frerichs |
Signed |
56 |
2020-02-07 15:17 |
Anonymous (not verified) |
204.153.176.73 |
J*M Fuels, LLC |
Limited Liability Company |
600 W Bremer Avenue, Waverly IA 50677 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-07 |
Jim Johnson |
mattjohnson7555@gmail.com |
Jackson TWP |
Butler |
Iowa |
Ty Burke |
Lori Frerichs |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ty Burke |
tburke@acceladvantage.com |
Agent |
Waverly |
IA |
United States |
Tony Pollastrini |
Lori Frerichs |
Signed |
663 |
2021-10-04 09:45 |
Anonymous (not verified) |
166.181.80.1 |
Matthew Winters |
Proprietorship |
9220 Summit Dr 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. |
2021-10-04 |
Matthew Winters |
mattwinters55@gmail.com |
Johnston |
Polk |
Iowa |
Brittany Strub |
Judy Sansom |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Winters |
mattwinters55@gmail.com |
Self |
Johnston |
Polk |
Iowa |
Brittany Strub |
Judy Sansom |
Signed |
1012 |
2022-03-28 14:42 |
Anonymous (not verified) |
97.125.50.9 |
Charles Grimes |
Proprietorship |
1041 NW Victoria Ln, Waukee, IA 50263 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-28 |
Charles Grimes |
maurcedes98@gmail.com |
Waukee |
Dallas |
Iowa |
Dave Tomlin |
Lavon Grimes |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Charles Grimes |
maurcedes98@gmail.com |
self |
Waukee |
Dallas |
IA |
Dave Tomlin |
Lavon Grimes |
Signed |
1702 |
2023-06-22 22:57 |
Anonymous (not verified) |
94.188.207.230 |
A&M Consulting LLC |
Limited Liability Company |
1208 5th Ave, North Humboldt Iowa, 50548 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
maureen Waweru |
maureenrealtyaz@yahoo.com |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
maureen Waweru |
maureenrealtyaz@yahoo.com |
Self |
chandler |
AZ |
United States |
John Waweru |
Jessica Bellinger |
Signed |
1910 |
2023-11-15 13:06 |
Anonymous (not verified) |
94.188.207.228 |
RODRIGUEZ ENTERPRISES III INC |
Limited Liability Company |
905 W US HIGHWAY 30 CARROLL IA 51401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-14 |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
CARROLL |
CARROLL |
IOWA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MAURO RODRIGUEZ |
mauro15o1@hotmail.com |
OWNER |
CARROLL |
CARROLL |
IA |
GONZALO MUNOZ |
SILVIA CHAVEZ |
Signed |
897 |
2022-02-04 15:15 |
Anonymous (not verified) |
163.116.133.119 |
Schauf Investments LLC |
Limited Liability Company |
3465 Vermont Street, New Virginia, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-04 |
Maxwell Schauf |
max.schauf@gmail.com |
New Virginia |
IA |
United States |
Krisha Schauf |
Robin Schauf |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maxwell Schauf |
max.schauf@gmail.com |
General Member |
New Virginia |
IA |
United States |
Krisha Schauf |
Robin Schauf |
Signed |
574 |
2021-07-14 10:43 |
Anonymous (not verified) |
173.27.17.202 |
Maxwell Taylor |
Proprietorship |
618 east Colorado St. Davenport Iowa 52803 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-14 |
Maxwell Taylor |
maxwelltaylor33@icloud.com |
Davenport |
Scott |
Iowa |
Jacob Nagel |
Ty Reindl |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maxwell Taylor |
maxwelltaylor33@icloud.com |
Self |
Davenport |
Scott |
Iowa |
Jacob Nagel |
Ty Reindl |
Signed |
563 |
2021-07-08 12:16 |
Anonymous (not verified) |
173.17.250.209 |
Forest Avenue Outreach |
Limited Liability Company |
1600 6th Ave DSM IA 50314 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-07-08 |
Maya Bromolson |
maya@goodvibesmovement.org |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Maya Bromolson |
maya@goodvibesmovement.org |
Executive Director |
Des Moines |
IA |
United States |
Joel Donaghy |
Brian Donaghy |
Signed |
335 |
2020-12-08 11:08 |
Anonymous (not verified) |
173.18.16.129 |
quintanillas construction llc |
Limited Liability Company |
3136 6th ave des moines ia 50313 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-12-08 |
maynor quintanilla |
maynorquintanilla42@gmail.com |
des moines |
polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
maynor quintanilla |
maynorquintanilla42@gmail.com |
owner |
des moines |
polk |
Iowa |
Lesa Reeves |
Jen Lambert |
Signed |
180 |
2020-06-09 13:35 |
Anonymous (not verified) |
99.203.113.208 |
Z & Sons handyman company LLC |
Limited Liability Company |
2701 E Market St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-09 |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Des Moines |
Polk |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Z & Sons handyman company LLC is owned by agent |
Des Moines |
Polj |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
181 |
2020-06-09 20:44 |
Anonymous (not verified) |
75.162.15.198 |
Z & Sons handyman company LLC |
Limited Liability Company |
2701 E Market St Des Moines Iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-09 |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Des Moines |
Polk |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Miguel Angel Zuniga |
mazuniga123678@gmail.com |
Z & Sons handyman company LLC is owned by agent |
Des Moines |
Polk |
Iowa |
Rosario Zuniga |
Christina Zuniga |
Signed |
1181 |
2022-07-06 10:10 |
Anonymous (not verified) |
173.18.22.217 |
MB Masonry LLC |
Limited Liability Company |
PO Box 7534 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-06 |
Mirela Atajic |
mbmasonryllc@yahoo.com |
Urbandale |
Polk |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mirela Atajic |
mbmasonryllc@yahoo.com |
Owner |
Urbandale |
Polk |
Iowa |
Lesa Reeves |
Jennifer Lambert |
Signed |
17 |
2019-12-31 09:24 |
Anonymous (not verified) |
72.35.186.80 |
Grgurich Dozing & Tiling, LLC |
Partnership |
PO Box 131, Williamson, IA 50272 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-31 |
Seth Grgurich |
mcbroomt15@gmail.com |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Seth Grgurich |
mcbroomt15@gmail.com |
Partner |
Williamson |
Lucas |
Iowa |
Eric Curran |
Stacy Smyser |
Signed |
1150 |
2022-06-10 16:14 |
Anonymous (not verified) |
173.29.125.38 |
Vernon Tim McClain |
Limited Liability Company |
2717 Thompson ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-10 |
Vernon Tim McClain |
mcclainlawn@gmail.com |
Des Moines |
POlk |
Iowa |
Ilisha Carter |
Earl Warren Jr. |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
vernon mcclain |
mcclainlawn@gmail.com |
business owner |
des moines |
polk |
iowa |
Ilisha Carter |
Earl Warren Jr. |
Signed |
370 |
2021-01-22 14:23 |
Anonymous (not verified) |
71.39.227.238 |
Jonathon McClure |
Proprietorship |
25059 R Ave, Dallas Center, IA 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-22 |
Jonathon McClure |
mcclure.jonathon@gmail.com |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jonathon McClure |
mcclure.jonathon@gmail.com |
Self |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
543 |
2021-06-16 12:49 |
Anonymous (not verified) |
174.250.64.145 |
McCulloch Construction LLC |
Limited Liability Company |
2590 SE 68TH ST |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-01 |
Scott Rouse |
MCCULLOCHCONSTRUCTION78@GMAIL.COM |
PLEASANT HILL |
Polk |
IA |
Joel Rouse |
Shonna Rouse |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Scott Rouse |
MCCULLOCHCONSTRUCTION78@GMAIL.COM |
Owner |
PLEASANT HILL |
Polk |
IA |
Joel Rouse |
Shonna Rouse |
Signed |
1742 |
2023-07-12 12:43 |
Anonymous (not verified) |
94.188.207.228 |
Old Glory Home Improvements LLC |
Limited Liability Company |
117 E Church st, Panora, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-12 |
Laden Binjiman McDonald |
mcdonaldladen@gmail.com |
Waukee |
Dallas |
Iowa |
Tina McDonald |
Matt McDonald |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Northwest Registered Agent |
bmartin@frannet.com |
Employer |
Panora |
Guthrie |
Iowa |
Tina McDonald |
Matt McDonald |
Signed |
675 |
2021-10-15 11:22 |
Anonymous (not verified) |
75.162.156.37 |
MCG FLOORING, LLC |
Limited Liability Company |
2115 CARPENTER AVE 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. |
2021-10-15 |
GABRIELA GOMEZ |
MCGFLOORINGLLC@GMAIL.COM |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MCG FLOORING, LLC |
MCGFLOORINGLLC@GMAIL.CON |
OWNER |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
676 |
2021-10-15 11:29 |
Anonymous (not verified) |
75.162.156.37 |
MCG FLOORING, LLC |
Limited Liability Company |
2115 CARPENTER AVE 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-10-15 |
MANUEL CONTRERAS BERNAL |
MCGFLOORINGLLC@GMAIL.COM |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
MCG FLOORING, LLC |
MCGFLOORINGLLC@GMAIL.CON |
OWNER |
DES MOINES |
USA |
IA |
YOLANDA MENDOZA |
LILIANA SANCHEZ GUTIERREZ |
Signed |
41 |
2020-01-20 14:26 |
Anonymous (not verified) |
173.24.181.211 |
BARBARA HOOGEVEEN |
Proprietorship |
304 MILL POND RD, 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. |
2020-01-20 |
BARBARA HOOGEVEEN |
MCGILLH@MTCNET.NET |
ROCK RAPIDS |
LYON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
BARABARA HOOGEVEEN |
MCGILLH@MTCNET.NET |
OWNER |
ROCK RAPIDS |
LYON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
1951 |
2023-12-12 13:10 |
Anonymous (not verified) |
94.188.207.230 |
Patrick McGuinnis |
Limited Liability Company |
5697 Squire Circle, Thomson, IL 61285 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-09 |
Patrick A McGinnis |
McGinnistrucking2023@yahoo.com |
Thomson |
Carroll |
IL |
Ashleigh McGuinnis |
Kimberly Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Parick A McGunnis |
mcginnistrucking2023@yahoo.com |
Self |
Thomson |
Carroll |
IL |
Ashleigh McGinnis |
Kimberly Williams |
Signed |
1972 |
2024-01-02 14:19 |
Anonymous (not verified) |
94.188.205.174 |
Parker Trucking LLC |
Limited Liability Company |
1507 Greene Street Adel, IA 50003 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-01-02 |
Michael Craig Parker |
mcparker31@msn.com |
Adel |
Dallas |
Iowa |
Jessie Rynearson |
Melisha Rynearson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Parker |
mcparker31@msn.com |
Owner/Memeber |
Adel |
Dallas |
IA |
Jessie Rynearson |
Melishia Rynearson |
Signed |
371 |
2021-01-22 14:25 |
Anonymous (not verified) |
71.39.227.238 |
Michael McClure |
Proprietorship |
2553 240th St, Dallas Center, IA 50063 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-22 |
Michael McClure |
mdjj4@centurylink.net |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael McClure |
mdjj4@centurylink.net |
Self |
Dallas Center |
Dallas |
Iowa |
RoseMary Phillips |
Steve Phillips |
Signed |
1777 |
2023-08-03 14:21 |
Anonymous (not verified) |
94.188.207.227 |
Mark Doty |
Proprietorship |
509 Parwood Circle, Huxley, IA 50124 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-03 |
Mark Doty |
mdoty@dakotagrown.com |
Huxley |
Story |
IA |
Rebecca R Moeller |
Jeffery F Vanasse |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Rebecca R Moeller |
Becky@northernlines.net |
Agent |
Fairmont |
MN |
United States |
Rebecca R Moeller |
Jeffery F Vanasse |
Signed |
643 |
2021-09-17 11:17 |
Anonymous (not verified) |
167.142.95.56 |
Preferred Properties of Iowa, Inc. |
Limited Liability Company |
500 W. Temple St., Lenox, IA 50851 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-17 |
Mark Pearson |
mdpearson88@gmail.com |
Corning |
Adams |
Iowa |
Ron Travis |
Maury Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Zech |
dan.ppi@gmail.com |
Owner |
Lenox |
Taylor |
Iowa |
Ron Travis |
Maury Moore |
Signed |
644 |
2021-09-17 11:20 |
Anonymous (not verified) |
167.142.95.56 |
Preferred Properties of Iowa, Inc. |
Limited Liability Company |
500 W. Temple St., Lenox, IA 50851 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-17 |
Brennan Kester |
mdpearson88@gmail.com |
Corning |
Taylor |
Iowa |
Ron Travis |
Maury Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Zech |
dan.ppi@gmail.com |
owner |
Lenox |
Taylor |
Iowa |
Ron Travis |
Maury Moore |
Signed |
1707 |
2023-06-25 10:39 |
Anonymous (not verified) |
94.188.207.224 |
Michael D Ray |
Proprietorship |
4944 Holcomb Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-06-22 |
Michael D Ray Jr |
mdray01@msn.com |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael D Ray |
mdray01@msn.com |
Owner Proprietor |
Des Moines |
Polk |
Iowa |
Bonnie R Finken |
Isaiah O Washington |
Signed |
1048 |
2022-04-14 14:17 |
Anonymous (not verified) |
208.38.229.255 |
Mean Green Lawn Care |
Limited Liability Company |
2628 W 59th st Davenport Iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Anthony mccash |
meangreenlawncare20@gmail.com |
Davenport |
Scott |
Iowa |
Clarissa Oliva |
Julie Thornman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Anthony McCash |
meangreenlawncare20@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Clarissa Oliva |
Julie Thornman |
Signed |
634 |
2021-09-10 13:41 |
Anonymous (not verified) |
173.23.145.231 |
julio medina |
Proprietorship |
609 boyd st. des moines, iowa 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. |
2021-09-10 |
julio medina |
medinajulio10001@gmail.com |
des moines |
polk |
iowa |
jose rivas |
Virginia Gomez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Julio Medina |
medinajulio10001@gmail.com |
owner |
des moines |
polk |
iowa |
jose Rivas |
Virginia Gomez |
Signed |
1104 |
2022-05-16 13:00 |
Anonymous (not verified) |
65.144.174.26 |
Medrano Flooring LLC |
Limited Liability Company |
8186 Harbach Blvd Apt 1, Clive, IA 50325 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-16 |
Joel Medrano |
medranojoel397@gmail.com |
Clive |
Polk |
Iowa |
Ana Leon |
Jesus Maldonado |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Joel Medrano |
medranojoel397@gmail.com |
Self |
Clive |
Polk |
Iowa |
Ana Leon |
Jesus Maldonado |
Signed |
1971 |
2023-12-29 19:27 |
Anonymous (not verified) |
94.188.207.223 |
Megan Thibodeau |
Proprietorship |
4301 Adams Ave, Des Moines, IA 50310 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-29 |
Megan E Thibodeau |
megancallan@hotmail.com |
Des Moines |
Iowa |
United States |
Travis Releford |
Courtney Releford |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Megan E Thibodeau |
megancallan@hotmail.com |
Self |
Des Moines |
Iowa |
United States |
Travis Releford |
Courtney Releford |
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 |
1884 |
2023-10-27 18:32 |
Anonymous (not verified) |
94.188.205.177 |
J&M dry wall |
Proprietorship |
948 Kern St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-27 |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Waterloo |
Black hawk |
IA |
Luis flores |
Luis flores |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melecio Zacarias-Cano |
Meleciozacarias29@gmail.com |
Self |
Waterloo |
Black hawk |
IA |
Luis Flores |
Luis flores |
Signed |
530 |
2021-05-25 08:30 |
Anonymous (not verified) |
159.242.43.24 |
FoxTrot Foods, LLC |
Limited Liability Company |
13-15 S Federal Ave, Mason City IA 50401 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-05-25 |
Melissa Fabian |
melissafabian@yahoo.com |
Mason City |
Cerro Gordo |
Iowa |
Jenny McIntyre |
Dan Wunschel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Fabian |
melissafabian@yahoo.com |
Owner-Member |
Mason City |
Cerro Gordo |
Iowa |
Jenny McIntyre |
Dan Wunschel |
Signed |
1621 |
2023-05-01 15:53 |
Anonymous (not verified) |
94.188.207.226 |
Hearing Health Care |
Limited Liability Partnership |
2519 S 16TH 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. |
2023-05-01 |
Melissa Knoell |
MELISSAKNOELL@YAHOO.COM |
COUNCIL BLFS |
IA |
IA |
Bruce Carol Johnk |
Marcelyn Maureen Johnk |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Melissa Knoell |
melissaknoell@yahoo.com |
self |
Council Bluffs |
Pottawattomi |
IA |
Bruce Carol Johnk |
Marcelyn Maureen Johnk |
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 |
1293 |
2022-09-03 08:03 |
Anonymous (not verified) |
50.82.244.98 |
MTZ Drywall |
Proprietorship |
1101 Eighth St, West Des Moines, IA |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-09-02 |
Richar Martinez |
menace_42@icloud.com |
West Des Moines |
United States |
Iowa |
Alejandro Gonzalez |
Emilio Martinez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jerry Jenkins |
jjenkins@farmersagent.com |
N/A |
Urbandale |
United States |
Iowa |
Alejandro Gonzalez |
Emilio Martinez |
Signed |
1380 |
2022-11-26 07:41 |
Anonymous (not verified) |
173.17.229.18 |
M&M Construction LLC |
Limited Liability Company |
32785 Homestead Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-11-23 |
Amparo Yamilet Menendez Gonzalez |
menendez.amparo@yahoo.com |
Granger |
Dalles center |
United States |
Carla Diaz |
Jesus Lopez |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gerardo Alvarado |
bariel578@gmail.com |
Employee |
Perry |
IA |
United States |
Carla Diaz |
Jesus lopez |
Signed |
209 |
2020-07-19 17:02 |
Anonymous (not verified) |
173.189.166.183 |
Merle Fox |
Proprietorship |
314 N Jackson St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-19 |
Merle T Fox |
merletravisfox.79@gmail.com |
Lisbon |
Linn |
Iowa |
Dustin Ohlfest |
Chelsea Brown |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Merle Fox |
merletravisfox.79@gmail.com |
self |
Lisbon |
Linn |
Iowa |
Dustin Ohlfest |
Chelsea Brown |
Signed |
2021 |
2024-02-02 10:12 |
Anonymous (not verified) |
94.188.207.227 |
JUSIC ENTERPRISES LLC DBA MJS TREE SERVICE |
Limited Liability Company |
11619 NW 106TH AVE GRANGER, IA 50109 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-02-02 |
MERSUDIN JUSIC |
MERSO.JUSIC@GMAIL.COM |
GRANGER |
POLK COUNTY |
IOWA |
RICHARD BALES |
ZACHARY SMITH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MERSUDIN JUSIC |
MERSO.JUSIC@GMAIL.COM |
MEMBER OWNER |
GRANGER |
POLK |
IOWA |
RICH BALES |
ZACHARY SMITH |
Signed |
1835 |
2023-09-09 15:11 |
Anonymous (not verified) |
94.188.207.224 |
Heartland Ultrasonography Group |
Limited Liability Company |
1015 Woodland Dr Carlisle, IA 50047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-09-09 |
Micah Ezra Wiele |
mewiele99@gmail.com |
Ankeny |
Polk |
Iowa |
Nathan Miguel Diaz |
Brandon Allen Pemoulie |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Micah Ezra Wiele |
heartlandusgroup@outlook.com |
Co-owner |
Ankeny |
Polk |
Iowa |
Nathan Miguel Diaz |
Brandon Allen Pemoulie |
Signed |
412 |
2021-02-23 14:23 |
Anonymous (not verified) |
205.185.135.176 |
Jeffrey Meyer |
Proprietorship |
118 1st St SE New Albin IA 52160 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-23 |
Jeffrey Meyer |
meyertimberservices@gmail.com |
New Albin |
Allamakee |
Iowa |
Michael Klug |
Kayla Snitker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Klug |
mike@aibme.com |
Insurance Agent |
Caledonia |
Houston |
Minnesota |
Jeffrey Meyer |
Kayla Snitker |
Signed |
1760 |
2023-07-26 08:16 |
Anonymous (not verified) |
94.188.207.230 |
MCH Pig LLC |
Limited Liability Company |
5434 180th Ave Albert City, IA 50510 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-26 |
Mitchell Hogrefe |
mhogrefe@nfpinc.com |
Newell |
Buena Vista |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchell Hogrefe |
mhogrefe@nfpinc.com |
Owner |
Newell |
Buena Vista |
Iowa |
Kyle Klein |
Brenda Klein |
Signed |
96 |
2020-03-19 12:11 |
Anonymous (not verified) |
173.24.181.211 |
JENSEN GROUP LP |
Limited Liability Partnership |
PO BOX 721 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. |
2020-03-18 |
MICHAEL JENSEN |
Michael@BuyGreatLakes.com |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MICHAEL JENSEN |
JOEL@WALKERINSURANCE.COM |
PARTNER |
ARNOLDS PARK |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
TAMI SUE KLEIN |
Signed |
173 |
2020-06-04 11:22 |
Anonymous (not verified) |
167.142.93.121 |
Chad Hauschild dba Chad Hauschild Logging |
Proprietorship |
23864 190th St, Farmersburg, IA 52047 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-04 |
Chad Hauschild |
michael@giffordinsurance.net |
Farmersburg |
Clayton |
Iowa |
Angela Keppler |
Kevin Lau |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Chad Hauschild |
michael@giffordinsurance.net |
Self |
Farmersburg |
Clayton |
Iowa |
Angela Keppler |
Kevin Lau |
Signed |
793 |
2021-12-14 14:16 |
Anonymous (not verified) |
174.22.96.99 |
Dubuque County Energy District |
Limited Liability Company |
700 Locust Street, #195 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-10 |
Michaela Marie Freiburger |
michaela@energydistrict.org |
Dubuque |
Dubuque |
IA |
Diane Freiburger, Mother |
Michael Freiburger, Father |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michaela Marie Freiburger |
michaela@energydistrict.org |
Contracted Vendor for the Dubuque County Energy District |
Dubuque |
Dubuque |
IA |
Diane Freiburger |
Michael Freiburger |
Signed |
1934 |
2023-12-01 22:43 |
Anonymous (not verified) |
94.188.207.224 |
wasabi johnston llc |
Limited Liability Company |
7115 ridgedale ct, johnston, IA, 50131 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-01 |
wenhui chen |
michaelchen@wasabidsm.com |
johnston |
polk |
Iowa |
wen Zheng |
Jenna Yu |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
wenhui chen |
michaelchen@wasabidsm.com |
owner |
johnston |
polk |
IOWA |
wen zheng |
Jenna Yu |
Signed |
1991 |
2024-01-17 00:34 |
Anonymous (not verified) |
94.188.207.223 |
Wasabi urbandale llc |
Limited Liability Company |
7115 Ridgedale 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. |
2024-01-17 |
Wenhui chen |
michaelchen@wasabidsm.com |
Johnston |
Polk |
Iowa |
Yilian lin |
Ji jie jie |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Wenhui chen |
michaelchen@wasabidsm.com |
Owner |
Johnston |
Polk |
Iowa |
Yilian lin |
Ji jie jie |
Signed |
317 |
2020-11-15 19:20 |
Anonymous (not verified) |
172.58.83.192 |
All Cut Lawn Care |
Proprietorship |
3506 Glover Ave. Des Moines Iowa 50315 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-11-15 |
Michael D Money |
michaelmoney883@gmail.com |
Des Moines |
Polk |
Iowa |
Deanna L Phagan |
Diana J Jennings |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael D Money |
michaelmoney883@gmail.com |
Myself |
Des Moines |
Polk |
Iowa |
Deanna L Phagan |
Diana J Jennings |
Signed |
577 |
2021-07-16 13:45 |
Anonymous (not verified) |
204.155.61.217 |
Chris & Michele Burke dba Studio Dance |
Proprietorship |
3907 Center Point Rd NE, Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2021-07-16 |
Michele Burke |
michele@studiodanceia.com |
Marion |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Michele Burke |
michele@studiodanceia.com |
owner |
Marion |
Linn |
Iowa |
Molly Feldman |
Sharon Naber |
Signed |
1795 |
2023-08-11 08:02 |
Anonymous (not verified) |
94.188.205.176 |
Overall Cleaning |
Proprietorship |
507 Enterprise Ct #6 Independence IA 50644 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-11 |
Michelle L. Vonsprecken |
michelle.vonsprecken@gmail.com |
Independence |
Buchanan |
Iowa |
Jacob Von Sprecken |
Cody Caraway |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Justin C Hayes |
overallcleaning21@gmail.com |
Business Partner |
Marion |
Linn |
IA |
Cody Caraway |
Jacob Von Sprecken |
Signed |
1052 |
2022-04-14 19:05 |
Anonymous (not verified) |
140.82.187.220 |
McHaddy Constuction |
Proprietorship |
423 Railroad St. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-14 |
Mick Haddeman |
mick@mchaddyconstruction.com |
Hudson |
Iowa |
United States |
Linsey Jo Haddeman |
Jordan Renae Haddeman |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Haddeman |
mick@mchaddyconstruction.com |
self |
Hudson |
IA |
United States |
Linsey Jo Haddeman |
Jordan Renae Haddeman |
Signed |
1347 |
2022-10-26 14:42 |
Anonymous (not verified) |
173.21.223.66 |
Mid American Roofing |
Limited Liability Company |
811 8th St Kalona IA 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-26 |
Josiah Hoyt |
midamericanroofing@gmail.com |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Josiah Hoyt |
josiahhoyt@gmail.com |
Owner |
KALONA |
IA |
United States |
Jensen Ropp |
Randy Ropp |
Signed |
1127 |
2022-05-25 18:12 |
Anonymous (not verified) |
216.51.235.160 |
Midwest Excavation & Trucking LLC |
Limited Liability Company |
21324 Spring Ave Clarksville, Ia 50670 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-05-25 |
Jared Stephen Ragsdale |
Midwest.excavation.llc@gmail.com |
Clarksville |
Butler |
Iowa |
Dave Johnson |
Patrick Lursen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jared Stephen Ragsdale |
Midwest.excavation.llc@gmail.com |
Myself |
Clarksville |
Butler |
Iowa |
Dave Johnson |
Patrick Lursen |
Signed |
1410 |
2023-01-06 10:58 |
Anonymous (not verified) |
173.25.103.95 |
Bryce Kenworthy |
Proprietorship |
155 NW Maple St 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. |
2023-01-06 |
Bryce Kenworthy |
midwest.fencingandconstruction@gmail.com |
Elkhart |
Polk |
Iowa |
Kevin Corn |
Nicole Almburg |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bryce Kenworthy |
midwest.fencingandconstruction@gmail.com |
Owner |
Elkhart |
Polk |
Iowa |
Kevin Corn |
Nicole Almburg |
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 |
1765 |
2023-07-27 14:27 |
Anonymous (not verified) |
94.188.207.225 |
Midwest Systems |
Proprietorship |
2877 130th St |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-27 |
Matt Griswold |
midwestsystems@live.com |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Griswold |
midwestsystems@live.com |
Owner |
Aurora |
IA |
United States |
Creatleigh Griswold |
Carslyn Griswold |
Signed |
1660 |
2023-05-24 10:11 |
Anonymous (not verified) |
94.188.205.177 |
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 |
Meredith Whitney Might |
mightlawncare@gmail.com |
Davenport |
Scott |
IA |
Samuel Lawrence Might |
Suzette Henriksen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meredith Might |
mightlawncare@gmail.com |
Owner |
Davenport |
Scott |
IA |
Samuel Lawrence Might |
Suzette Henriksen |
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 |
26 |
2020-01-04 17:23 |
Anonymous (not verified) |
45.53.67.52 |
Gary De Jager |
Limited Liability Company |
417 florida Ave NW Orange City Iowa 51041 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-04 |
Gary Dean De Jager |
mightyspear60@yahoo.com |
Orange City |
Souix |
Iowa |
Brody Dean De Jager |
Tyler Ray De Jager |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gary Dean De Jager |
mightyspear60@yahoo.com |
owner |
Orange City |
souix |
Iowa |
Brody Dean De Jager |
Tyler Ray De Jager |
Signed |
895 |
2022-02-04 11:57 |
Anonymous (not verified) |
216.189.133.155 |
A1A Sandblasting (Iowa) |
Proprietorship |
334 main street S.W. |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-04 |
michael d marjama |
mike.orie@yahoo.com |
menahga |
MN |
United States |
Josh Louviere |
Kevin Tomperi |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
michael d marjama |
mike.orie@yahoo.com |
Owner |
menahga |
MN |
United States |
Josh Louviere |
Kevin Tomperi |
Signed |
862 |
2022-01-27 12:02 |
Anonymous (not verified) |
174.198.81.166 |
Big Bear Construction,LLC |
Limited Liability Company |
4508 Hiawatha Ave NE Cedar Rapids, IA 52402 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-27 |
Michael Allen Becker |
mike4bbc@gmail.com |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Kevin Paul Becker jr |
kbeckerbbc@gmail.com |
Brother/partner |
Cedar Rapids |
Linn |
Iowa |
Kenny McCracken |
Corey Becker |
Signed |
88 |
2020-03-11 15:45 |
Anonymous (not verified) |
50.105.78.41 |
Al's Aerial Spraying, LLC |
Limited Liability Company |
3473 N Shepardsville Rd, Ovid MI 48866 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-03-11 |
Michael Schiffer |
Mike502B@aol.com |
Ovid |
Clinton |
MI |
Seth Alexander |
Nicholas Crofoot |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Albert Schiffer |
Al400@aol.com |
employee |
Ovid |
Clinton |
Michigan |
Seth Alexander |
Nicholas Crofoot |
Signed |
277 |
2020-10-08 14:21 |
Anonymous (not verified) |
173.18.16.129 |
Mb Construction and Real Estate LLC |
Limited Liability Company |
5375 Katelyn Ave Van Meter, IA 50261 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-08 |
Michael Mohr |
mike@mohrhomesia.com |
Van Meter |
Dallas |
Iowa |
Lesa Reeves |
Samantha Hartley-Bullen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MB Construction and Real Estate LLC |
mike@mohrhomesia.com |
Owner |
Van Meter |
Dallas |
Iowa |
Lesa Reeves |
Samantha Hartley-Bullen |
Signed |
365 |
2021-01-15 11:24 |
Anonymous (not verified) |
63.227.74.126 |
Paramount Kitchen and Bath |
Limited Liability Company |
2155 SE 37TH ST STE C |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-01-15 |
Michael Simpson |
mike@paramount-kitchens.com |
GRIMES |
Iowa |
United States |
Cory Morris |
Jason Andersen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Simpson |
mike@paramount-kitchens.com |
Owner |
GRIMES |
Iowa |
United States |
Cory Morris |
Jason Andersen |
Signed |
1217 |
2022-07-21 06:51 |
Anonymous (not verified) |
209.152.88.53 |
Bullard Accounting Services, LLC |
Limited Liability Company |
4519 Scouts View Dr, Central City, IA 52214 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-21 |
Michael Bullard |
mikeandkarenbullard@gmail.com |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Bullard |
mikeandkarenbullard@gmail.com |
President of Company |
CENTRAL CITY |
IA |
United States |
Karen Bullard |
Nicole Nassif |
Signed |
275 |
2020-10-08 11:56 |
Anonymous (not verified) |
166.224.213.71 |
Michael corcoran |
Proprietorship |
311 e elm st |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-07 |
Michael corcoran |
mikecorcoran1990@gmail.com |
West Union |
Fayette |
IA |
Heather corcoran |
Chris Fels |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael corcoran |
mikecorcoran1990@gmail.com |
Self |
West Union |
Fayette |
IA |
Heather corcoran |
Chris fels |
Signed |
800 |
2021-12-15 16:50 |
Anonymous (not verified) |
63.229.189.35 |
CT Home Services |
Limited Liability Company |
706 Jackson Avenue, Spirit lake, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-15 |
Mike Oolman |
mikecthome@gmail.com |
Spirit lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Oolman |
mikecthome@gmail.com |
Self |
Spirit Lake |
Dickinson |
Iowa |
Abigail Miles |
Alex Miles |
Signed |
1475 |
2023-02-21 18:42 |
Anonymous (not verified) |
94.188.207.230 |
Michael Goodyk Consgtruction |
Proprietorship |
2392 Keokuk Drive Pella, Iowa. 50219 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Michael Jay Goodyk |
mikegoodyk@gmail.com |
Pella |
Marion |
Iowa |
Joy Ekloffe |
Rick Ekloffe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Gorp Edwards insurance |
bwilliams@vangorpins.com |
Insurance Agent |
Pella |
Marion |
Iowa |
Joy Ekloffe |
Rick Ekloffe |
Signed |
290 |
2020-10-23 15:13 |
Anonymous (not verified) |
74.42.24.42 |
Gunter Trucking LLC |
Limited Liability Company |
704 River Ave N., Belmond, IA 50421 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-10-23 |
Michael James Gunter |
mikegunter885@yahoo.com |
Belmond |
Wright |
Iowa |
Sondra Faye Godsell |
Lori Lynn Studer |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael James Gunter |
mikegunter885@yahoo.com |
Owner |
Belmond |
Wright |
Iowa |
Sondra Faye Godsell |
Lori Lynn Studer |
Signed |
927 |
2022-02-17 16:22 |
Anonymous (not verified) |
174.215.244.78 |
Mike Benson dba Standard Drywall |
Proprietorship |
1713 w7th st. Waterloo iowa 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-17 |
Michael Arlyn Benson |
mikekimbenson@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Leesa Marie Wheeler |
Austin Michael Thorpe |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Arlyn Benson |
mikekimbenson@gmail.com |
Self |
Waterloo |
Black Hawk |
Iowa |
Leesa Marie Wheeler |
Austin Michael Thorpe |
Signed |
1426 |
2023-01-19 17:14 |
Anonymous (not verified) |
96.19.118.202 |
Tri State Certified LLC |
Limited Liability Company |
4755 Mayhew Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-01-19 |
Michael Tracy |
mikertracy755@gmail.com |
Sioux City |
IA |
United States |
Michael Tracy |
Michael Tracy |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tri State Certified LLC |
mikertracy755@gmail.com |
Owner |
Sioux City |
Iowa |
Iowa |
Michael Tracy |
Michael Tracy |
Signed |
1641 |
2023-05-11 13:40 |
Anonymous (not verified) |
94.188.207.228 |
Mike Weigel Construction, LLC |
Limited Liability Company |
2528 Dalton St, Ames IA 50010-1151 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Michael Patrick Weigel |
mikeweigelconstruction@gmail.com |
Ames |
Story |
Iowa |
Brenda Marie Weigel |
Piper Rylee Weigel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Michael Patrick Weigel |
mikeweigelconstruction@gmail.com |
Self |
Ames |
Story |
Iowa |
Brenda Marie Weigel |
Piper Rylee Weigel |
Signed |
221 |
2020-08-03 12:03 |
Anonymous (not verified) |
167.142.196.238 |
Israel Moreno |
Proprietorship |
Po Box 186 Williams, IA 50271 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-06-12 |
Israel Moreno |
mikjuniormoreno@hotmail.com |
Williams |
Hamilton |
Iowa |
Justin J Malloy |
Myndi Grimsley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Israel Moreno |
mikjuniormoreno@hotmail.com |
owner |
Williams |
Hamilton |
Iowa |
Justin J Malloy |
Myndi Grimsley |
Signed |
1453 |
2023-02-14 07:19 |
Anonymous (not verified) |
94.188.207.230 |
Milton Gray |
Proprietorship |
255 10th Ave., Marion, IA 52302, US |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-02-13 |
Milton Gray |
miltongray23@gmail.com |
Marion, IA |
Linn |
Iowa |
Jordan Nisiewicz |
Charles Wood |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jordan Nisiewicz |
jnisiewicz@leafhome.com |
Recruiter |
Kansas City |
Clay |
MO |
Charles Wood |
Steven Geisler |
Signed |
1729 |
2023-07-09 15:33 |
Anonymous (not verified) |
94.188.207.223 |
Melvin A mineros |
Limited Liability Company |
6209 Windsor dr des moines IA 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-07-09 |
Melvin A mineros |
minerosframing.llc@gmail.com |
Des moines |
Polk |
IA |
Orlando dominguez |
Isaac salazar |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jaime leiva |
jaime@boersmaninsurance.com |
Agent |
Des moines |
Polk |
IA |
Narciso hidalgo |
Balmore perez |
Signed |
1778 |
2023-08-03 14:52 |
Anonymous (not verified) |
94.188.207.227 |
Melvin A mineros |
Limited Liability Company |
6209 Windsor dr des moines IA 50312 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the 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. |
2023-06-22 |
Melvin alexander mineros |
minerosframing.llc@gmail.com |
Des moines |
Polk |
IA |
Orlando dominguez |
Isaac salazar |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Jaime leiva |
jaime@boersmaninsurance.com |
Agent |
Des moines |
Polk |
IA |
Narciso hidalgo |
Balmore perez |
Signed |
1015 |
2022-03-29 10:56 |
Anonymous (not verified) |
129.255.1.117 |
Alli Center |
Proprietorship |
1150 5th St Suite 270 Coralville, IA 52241 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Miranda K Maday |
miranda.maday@alli-center.com |
North Liberty |
Johnson |
Iowa |
Zara Wanlass |
Jason Knight |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Zara Wanlass |
zara.wanlass@alli-center.com |
Co-Owner and Business Manager |
Iowa City |
Johnson |
IA |
Miranda K Maday |
Jason Knight |
Signed |
2125 |
2024-03-28 23:17 |
Anonymous (not verified) |
94.188.207.223 |
MB Lawn Care |
Limited Liability Company |
7018 Deerview 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. |
2024-03-28 |
Mirnes Becirovic |
Mirnes2012@me.com |
Urbandale |
Polk |
Iowa |
Mirnes Becirovic |
Mirnes Becirovic |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mirnes Becirovic |
mirnes2012@me.com |
Owner |
Urbandale |
Polk |
Iowa |
Mirnes Becirovic |
Mirnes Becirovic |
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 |
27 |
2020-01-06 09:17 |
Anonymous (not verified) |
24.149.10.119 |
Miss Wonderful LLC |
Limited Liability Company |
216 Main St Cedar Falls, IA 50613 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-01-06 |
Ann Eastman |
misswonderful216@gmail.com |
Cedar Falls |
Black Hawk |
IA |
Rachel Lee |
Ann Remmert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Ann Eastman |
misswonderful216@gmail.com |
Owner |
Cedar Falls |
Black Hawk |
IA |
Rachel Lee |
Ann Remmert |
Signed |
1799 |
2023-08-14 14:42 |
Anonymous (not verified) |
94.188.205.174 |
Magiclean |
Proprietorship |
2001 S. 16th 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. |
2023-08-14 |
Sydney Bornsheuer |
Mistycale@gmail.com |
Burlington |
Iowa |
Iowa |
Dustina Fenton |
Doug Shupick |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Misty Cale |
magicleanburlington@gmail.com |
Owner |
Burlington |
Des Moines |
Iowa |
Dustina Fenton |
Doug Shupick |
Signed |
695 |
2021-10-26 17:22 |
Anonymous (not verified) |
208.126.118.243 |
Godes Farms Trucking LLC |
Limited Liability Company |
1698 270th Ave |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-10-26 |
Mitchel R Godes |
mitchelgodes@hotmail.com |
Delmar |
clinton |
iowa |
Dustin Kyarsgaard |
Mitch Moore |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mitchel R Godes |
mitchelgodes@hotmail.com |
owner |
Delmar |
Clinton |
iowa |
Dustin KKyarsgaard |
Mitch Moore |
Signed |
1319 |
2022-09-22 11:31 |
Anonymous (not verified) |
50.82.91.213 |
J. Thompson Builders, LLC |
Limited Liability Company |
5291 Stoney Creek 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. |
2022-10-22 |
Mark Grant |
mjgrant1957@gmail.com |
Adel |
Dallas |
IA |
Christina Viehauser |
Jeremy Thompson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Christina Viehauser |
christina@jthompsonbuilders.com |
Office Help |
Johnston Ia |
Polk |
IA |
Chris Von Arx |
Jeremy Thompson |
Signed |
1897 |
2023-11-06 09:12 |
Anonymous (not verified) |
94.188.205.177 |
Matthew Jones |
Limited Liability Company |
124 NE 49th Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-06 |
Matthew Jones |
mjj4242@gmail.com |
Ankeny |
Polk |
IA |
Duan Willform |
AJ Giebelstein |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Jones |
mjj4242@gmail.com |
Self |
Ankeny |
Polk |
IA |
AJ Giebelstein |
Duan Willform |
Signed |
721 |
2021-11-05 14:04 |
Anonymous (not verified) |
209.252.172.87 |
Mike Kraus |
Proprietorship |
212 2nd St Buffalo, Ia 52728 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-03-17 |
Mike Kraus |
mjkraus4356@gmail.com |
Buffalo |
Scott |
Iowa |
Heather Howell |
Sarah Coberley |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mike Kraus |
mjkraus4356@gmail.com |
Self Employed |
Buffalo |
Scott |
Iowa |
Sarah Coberley |
Heather Howell |
Signed |
58 |
2020-02-10 21:18 |
Anonymous (not verified) |
75.162.11.63 |
Moni tile Services llc |
Limited Liability Company |
2207 E Walnut St des Moines iowa 50317 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-02-01 |
Monica M Sandoval |
Mjsandoval20@yahoo.com |
Des Moines |
Polk |
United States |
Cassie Ann bentz |
James wesley harkert |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Moni tile services llc |
Mjsandoval20@yahoo.com |
Self |
Des Moines |
Polk |
Iowa |
Cassie Ann bentz |
James wesley harkert |
Signed |
213 |
2020-07-21 17:47 |
Anonymous (not verified) |
107.77.206.41 |
Sequoia integrative medical services |
Limited Liability Company |
W2560 birschbach drive, mount Calvary, WI 53057 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-07-16 |
Mary Kate friess |
mkfriess71@gmail.com |
Fond du lac |
Fond du lac |
WI |
Gordon Lewis |
Ron carpenter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mary Kate friess |
mkfriess71@gmail.com |
Self |
Fond du lac |
Fond du lac |
Wi |
Gordon Lewis |
Ron carpenter |
Signed |
764 |
2021-11-22 15:33 |
Anonymous (not verified) |
198.14.219.227 |
Central Iowa Painting and Contracting LLC |
Limited Liability Company |
408 Freel Drive, Ste. 101, Ames, IA 50010 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-22 |
Matthew Paul Klucas |
mklucas50@gmail.com |
Fort Dodge |
Webster County |
Iowa |
Jordan Watkins |
Scott Schuler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Klucas |
mklucas50@gmail.com |
Owner of Buisness |
Fort Dodge |
Webster County |
Iowa |
Jordan Watkins |
Scott Schuler |
Signed |
4 |
2019-11-12 09:06 |
Anonymous (not verified) |
174.71.54.19 |
M AND J LLC |
Limited Liability Company |
44100 STATE HIGHWAY 37 Dunlap, IA 51529 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-12 |
Mark Nichols |
mknichols2003@yahoo.com |
DUNLAP |
Monona |
IA |
Damon Nichols |
Bob Hall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Nichols |
mknichols2003@yahoo.com |
Partner |
Dunlap |
Monona |
IA |
Damon Nichols |
Bob Hall |
Signed |
5 |
2019-11-12 09:57 |
Anonymous (not verified) |
174.71.54.19 |
M AND J LLC |
Limited Liability Company |
44100 STATE HIGHWAY 37 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-11-12 |
M AND J, LLC |
mknichols2003@yahoo.com |
DUNLAP |
MONONA |
IA |
Damon Nichols |
Bob Hall |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
JAMES MUMM |
plipichok@yahoo.com |
Partner |
DUNLAP |
MONONA |
IA |
DAMON NICHOLS |
BOB HALL |
Signed |
15 |
2019-12-30 18:13 |
Anonymous (not verified) |
104.166.243.52 |
Matt Moore |
Proprietorship |
8450 Hickman Road #15C |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2019-12-30 |
Matt Moore |
mljm2016@outlook.com |
Clive |
Iowa |
Iowa |
Tom Onnen |
James Buffington |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matt Moore |
mljm2016@outlook.com |
Subcontractor |
Urbandale |
IOWA |
United States |
Tom Onnen |
James Buffington |
Signed |
145 |
2020-04-30 16:09 |
Anonymous (not verified) |
173.191.206.253 |
Mark Knapp |
Proprietorship |
11244 Linden Rd |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-30 |
Mark A Knapp |
mlmlknapp@iowatelecom.net |
Linden |
Iowa |
United States |
Phil Hesseltine |
Kathy Hesseltine |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Knapp |
mlmlknapp@iowatelecom.net |
self |
Linden |
Iowa |
United States |
Phil Hesseltine |
Kathy Hesseltine |
Signed |
619 |
2021-08-25 14:31 |
Anonymous (not verified) |
192.154.15.2 |
MAV Restorations LLC |
Limited Liability Company |
5461 Meadow Ct, Asbury, IA 52002 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-08-25 |
Matthew Vaske |
mlvaske@gmail.com |
Asbury |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Matthew Vaske |
mlvaske@gmail.com |
Self |
Asbury |
Dubuque |
IA |
Randi Taylor |
Carla Martin |
Signed |
1514 |
2023-03-13 10:04 |
Anonymous (not verified) |
94.188.205.166 |
MMK Electric |
Limited Liability Partnership |
4515 84th St 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. |
2023-03-13 |
Travis Miller |
mmk.iowa@gmail.com |
Urbandale |
Polk |
Iowa |
Elijah Kain |
Marshall McKay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Miller |
mmk.iowa@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Elijah Kain |
Marshall McKay |
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 |
1521 |
2023-03-16 14:26 |
Anonymous (not verified) |
94.188.207.229 |
Mmk electric |
Partnership |
4515 84th st Urbandale ia |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-03-16 |
Elijah dale kain |
mmk.iowa@gmail.com |
West Des moines |
Polk |
Iowa |
Travis Lee miller |
Marshall Logan McKay |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Travis Lee miller |
mmk.iowa@gmail.com |
Owner |
Urbandale |
Polk |
Iowa |
Travis Lee miller |
Marshall Logan mckay |
Signed |
660 |
2021-09-30 14:15 |
Anonymous (not verified) |
172.58.86.219 |
LeafFilter |
Limited Liability Company |
3060 SE Grimes Blvd. Suite 100-300, Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-30 |
Mohammed Albayati |
mmm2002faris@yahoo.com |
West Des Moines |
Polk |
Iowa |
Tammy Decker |
Yaseen Albayati |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mohammed Albayati |
albayatim28@gmail.com |
Employee |
Grimes |
Polk |
Iowa |
Tammy Decker |
Yaseen Albayati |
Signed |
1771 |
2023-08-01 09:59 |
Anonymous (not verified) |
94.188.207.223 |
Modern Builder LLC |
Limited Liability Company |
30008 560th St Chariton IA 50049 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-08-01 |
Tatyana Sayenko |
modernbuilder02@gmail.com |
Chariton |
Lucas |
Iowa |
Arthur Sayenko |
Viktor Sayenko |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Tatyana Sayenko |
modernbuilder02@gmail.com |
owner/ Family |
Chariton |
Lucas |
Iowa |
Arthur Sayenko |
Viktor Sayenko |
Signed |
1018 |
2022-03-29 15:00 |
Anonymous (not verified) |
97.125.143.50 |
Modified Originals of Winterset |
Limited Liability Company |
128 S 3rd Ave, Winterset, IA 50273 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-03-29 |
Daniel Maiers |
Modifiedoriginals.winterset@gmail.com |
Winterset |
Iowa |
Iowa |
Mark Haddinger |
Josh Williams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Dan Maiers |
Modifiedoriginals.winterset@gmail.com |
Self |
Winterset |
Iowa |
Iowa |
Mark Haddinger |
Josh Williamson |
Signed |
970 |
2022-03-14 14:08 |
Anonymous (not verified) |
174.199.79.176 |
Friends Transportation Services LLC |
Limited Liability Company |
6010 Creston Ave Unit 26, Des Moines, IA 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. |
2022-03-14 |
Mohammed Dood |
mohedali777@hotmail.com |
Des Moines |
Polk |
Iowa |
Leigh Laven |
Geoff Matlock |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mohammed Dood |
mohedali777@hotmail.com |
Owner |
Des Moines |
Polk |
Iowa |
Leigh Laven |
Geoff Matlock |
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 |
886 |
2022-02-03 10:21 |
Anonymous (not verified) |
217.180.228.144 |
Flo + Friends, LLC |
Limited Liability Company |
52480 HWY 210 Slater, IA. 50244 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-02-03 |
Molly S Onken |
mollyaols@gmail.com |
Slater |
Story |
Iowa |
Pam Wilson |
Todd Wilson |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Molly S Onken |
mollyaols@gmail.com |
self |
slater |
Story |
Iowa |
Pam Wilson |
Todd Wilson |
Signed |
1481 |
2023-02-24 12:45 |
Anonymous (not verified) |
94.188.207.223 |
Molly Onken |
Limited Liability Company |
52480 HWY 210 Slater, IA. 50244 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by 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 |
Molly S Onken |
mollyaols@gmail.com |
Slater |
Story |
Iowa |
Pamela A Wilson |
Lori Konzen |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Molly S Onken |
mollyaols@gmail.com |
Owner |
Slater |
Story |
Iowa |
Pamela A Wilson |
Lori Konzen |
Signed |
71 |
2020-02-21 05:24 |
Anonymous (not verified) |
70.100.107.197 |
CRS Inc. |
Proprietorship |
1442 3rd Ave 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. |
2020-01-20 |
Monica Christensen |
monicalchristensen@gmail.com |
Belmond |
Wright |
Iowa |
Jessica Tempus |
Dawn Butler |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Monica Christensen |
monicalchristensen@gmail.com |
Consultant |
Belmond |
Iowa |
United States |
Dawn Butler |
Jessica Tempus |
Signed |
1858 |
2023-10-03 13:29 |
Anonymous (not verified) |
94.188.207.223 |
Quad city drywall Solutions LLC |
Limited Liability Company |
5804 n thornwood ave Davenport iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-10-03 |
Erivan Emmanuel Montalvo Delcompare |
montalvobills6@gmail.com |
Davenport |
Scott |
Iowa |
Natalia Ann Montalvo |
Juan Portela |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erivan Emmanuel Montalvo Delcompare |
montalvobills6@gmail.com |
Owner |
Davenport |
Scott |
Iowa |
Natalia Montalvo |
Juan Portela |
Signed |
774 |
2021-11-29 12:28 |
Anonymous (not verified) |
174.198.82.208 |
Demetrio's Construction |
Proprietorship |
2018 Heights Ave Sioux City, IA 51104 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-11-29 |
Guillermo Demetrio |
moralesdalia44@yahoo.com |
Sioux City |
Woodbury |
Iowa |
Dalia E. Morales Galvez |
Vanessa Topete |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Guillermo Demetrio |
moralesdalia44@yahoo.com |
Owner |
Sioux City |
Woodbury |
Iowa |
Dalia Morales Galvez |
Vanessa Topete |
Signed |
1147 |
2022-06-08 11:29 |
Anonymous (not verified) |
67.55.184.250 |
Morgan Anderson |
Proprietorship |
23379 120th Ave, Mediapolis, IA 52637 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-06-08 |
Morgan Duane Anderson |
morgananderson6.ma@gmail.com |
Mediapolis |
IA |
United States |
Kelly S Lanz |
Monte A Lanz |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Morgan D. Anderson |
morgananderson6.ma@gmail.com |
sole proprietor |
Mediapolis |
Louisa |
Iowa |
Kelly Lanz |
Monte Lanz |
Signed |
262 |
2020-09-18 13:54 |
Anonymous (not verified) |
75.162.229.152 |
Morgan Group LLC |
Limited Liability Company |
1124 7th St. West Des Moines, IA 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-18 |
Mackinley Charles Morgan |
MORGANGROUPLLC@GMAIL.COM |
West Des Moines |
Polk |
Iowa |
Mark Steven Morgan |
Deborah Renee Morgan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mackinley Charles Morgan |
MorganGroupLLC@gmail.com |
Owner of Company |
West Des Moines |
Polk |
Iowa |
Mark Steven Morgan |
Deborah Renee Morgan |
Signed |
640 |
2021-09-16 22:43 |
Anonymous (not verified) |
97.125.255.204 |
Morgan Group LLC |
Limited Liability Company |
1124 7th St. West Des Moines, Iowa 50265 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-09-16 |
Mackinley Charles Morgan |
Morgangroupllc@gmail.com |
West Des Moines |
Polk |
Iowa |
Deborah Renee Morgan |
Mark Steven Morgan |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mackinley Charles Morgan |
Morgangroupllc@gmail.com |
Owner of company |
West Des Moines |
Polk |
Iowa |
Deborah Renee Morgan |
Mark Steven Morgan |
Signed |
1041 |
2022-04-12 09:39 |
Anonymous (not verified) |
173.31.148.43 |
PAPA'S SMOKIN MEAT |
Proprietorship |
1940 147TH ST SPIRIT LAKE, IA 51360 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-12 |
ROXANNE MORISTON |
MORISTON2@YAHOO.COM |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
ROXANNE MORISTON |
MORISTON2@YAHOO.COM |
SELF |
MONTGOMERY |
DICKINSON |
IA |
JOSEPH THOMAS LORING |
JENNIFER JANET YOUNGWIRTH |
Signed |
2158 |
2024-04-17 11:47 |
Anonymous (not verified) |
94.188.207.228 |
Mildred Lopez |
Proprietorship |
214 1st Ave SW Hampton, Iowa 50441 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Mark Morrison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Mark Morrison |
Signed |
2159 |
2024-04-17 12:28 |
Anonymous (not verified) |
94.188.207.229 |
Mildred Lopez Camacho |
Proprietorship |
214 1st Ave SW Hampton, Iowa 50441 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2024-04-17 |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Hampton |
Franklin |
Iowa |
Ixia Anduce |
Jonathan Morales |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mildred Lopez Camacho |
morrison.hpd@gmail.com |
Self |
Hampton |
Franklin |
IOwa |
Ixia Anduce |
Jonathan Morales |
Signed |
258 |
2020-09-15 13:14 |
Anonymous (not verified) |
50.83.182.140 |
Moyer Painting |
Proprietorship |
934 Norwood Drive |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-09-15 |
jerome Moyer |
moyer_painting@live.com |
Norwalk |
IA |
United States |
Sally Moyer |
Adam Adams |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
jerome b moyer |
moyer_painting@live.com |
Self |
norwalk |
IA |
United States |
sally moyer |
Adam Adams |
Signed |
1335 |
2022-10-17 11:32 |
Anonymous (not verified) |
71.39.227.238 |
PELZER AG LLC |
Limited Liability Company |
16864 280TH ST, REDFIELD, IA 50233 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-10-17 |
MATT PELZER |
MPELZERFARMS@GMAIL.COM |
REDFIELD |
DALLAS |
IOWA |
ABBEY LUELLEN |
DON RICHARDSON |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
MATT PELZER |
MPELZERFARMS@GMAIL.COM |
PRESIDENT |
REDFIELD |
DALLAS |
IOWA |
ABBEY LUELLEN |
DON RICHARDSON |
Signed |
1144 |
2022-06-06 15:51 |
Anonymous (not verified) |
63.152.93.184 |
Mark Moser |
Limited Liability Company |
904 W 4th St., Waterloo Iowa 50702 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-02 |
Mark Moser |
mpmmoser@gmail.com |
Waterloo |
Black Hawk |
Iowa |
Timothy Combs |
Teresa Tjaden |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Mark Moser |
mpmmoser@gmail.com |
none |
Waterloo |
Black Hawk |
Iowa |
Timothy Combs |
Teresa Tjaden |
Signed |
815 |
2021-12-28 12:29 |
Anonymous (not verified) |
173.29.239.122 |
Comtek, Inc. |
Proprietorship |
3702 NW 13th St. Ankeny, Iowa 50023 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-12-28 |
Micheal D. Qualley |
mqcomtek@gmail.com |
ANKENY |
IA |
United States |
Jacque Blackman |
Jeffery Keipper |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Jacque Blackman |
jblackman@grimesfinancialgroup.com |
client |
Grimes |
Polk |
Iowa |
Jacque Blackman |
Jeffery Keipper |
Signed |
1927 |
2023-11-29 13:13 |
Anonymous (not verified) |
94.188.207.228 |
Yaardman landscaping llc |
Limited Liability Company |
51623 se seet cedar rapids iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-11-29 |
Adrian Pink |
Mr.Pink1118@gmail.com |
CEDAR RAPIDS |
IA |
United States |
Andrea Parker |
Kamar James |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adrian Pink |
Mr.Pink1118@gmail.com |
Owner |
CEDAR RAPIDS |
IA |
United States |
Andrea Parker |
Kamar James |
Signed |
1938 |
2023-12-05 11:54 |
Anonymous (not verified) |
94.188.207.225 |
Genius automotive |
Limited Liability Company |
51623 se seet cedar rapids iowa |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2023-12-05 |
Adrian Pink |
Mr.Pink1118@gmail.com |
CEDAR RAPIDS |
IA |
United States |
Andrea Parker |
Kamar james |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Adrian Pink |
Mr.Pink1118@gmail.com |
None |
CEDAR RAPIDS |
IA |
United States |
Andrea Parker |
Kamar James |
Signed |
1233 |
2022-07-28 22:53 |
Anonymous (not verified) |
166.181.84.53 |
Leaffilter |
Limited Liability Company |
3060 SE Grimes Blvd Suite 100-300, Grimes, IA 501113060 SE Grimes Blvd Suite 100-300, Grimes, IA 50111 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-28 |
Mohammed Albayati |
mrcarbody.81@gmail.com |
Johnston |
Polk |
Iowa |
Tammy Decker |
Waffa Albayati |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Meghan Mcilhon |
mmcilhon@leaffilter.com |
Human Resources |
Grimes |
Polk |
Iowa |
Tammy Decker |
Waffa Albayati |
Signed |
411 |
2021-02-22 15:58 |
Anonymous (not verified) |
173.24.190.134 |
The Willow Tree Garden Center |
Limited Liability Company |
2103 19rh Street, Emmetsburg IA 50536 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-02-22 |
Erica Janssen |
mrjanz13@gmail.com |
Emmetsburg |
Palo Alto |
Iowa |
Marilee Lace |
Candie Clark |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Erica Janssen |
mrjanz13@gmail.com |
Member of LLC |
Emmetsburg |
Palo Alto |
Iowa |
Marilee Lace |
Candie Clark |
Signed |
1030 |
2022-04-05 06:27 |
Anonymous (not verified) |
172.58.86.173 |
MR Roofing LLC |
Limited Liability Company |
8012 Ashridge Rd. Fort Worth, Tx 76134 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-04-05 |
MR Roofing LLC |
mrroofing.pr@gmail.com |
Fort Worth |
Tarrant |
Texas |
Juan M. Robledo |
Jose A. Robledo |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Paul Robledo |
mrroofing.pr@gmail.com |
Owner |
Fort Worth |
Tarrant |
Texas |
Juan M. Robledo |
Jose A. Robledo |
Signed |
1223 |
2022-07-22 15:14 |
Anonymous (not verified) |
167.142.255.81 |
HomeOwner's Helper LLC |
Limited Liability Company |
111 4th Ave, Underwood, IA 51576 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-07-22 |
Bradley W Syndergaard |
mrslouie8@yahoo.com |
UNDERWOOD |
Iowa |
United States |
Stacy L Louison |
Brent C Louison |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Bradley W Syndergaard |
mrslouie8@yahoo.com |
Self |
UNDERWOOD |
Iowa |
United States |
Stacy L Louison |
Brent C Louison |
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 |
840 |
2022-01-14 10:58 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Matthew Shear |
mshear@midwestsolarservices.com |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
841 |
2022-01-14 15:23 |
Anonymous (not verified) |
173.29.218.216 |
Midwest Solar Services, LLC |
Limited Liability Company |
595 Huff Street, 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. |
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
2022-01-10 |
Matthew Shear |
mshear@midwestsolarservices.com |
Hanover |
Jo Daviess |
IL |
Kim Esser |
Michelle Huss |
Signed |
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me. |
Midwest Solar Services, LLC |
kim.esser@kunkel-inc.com |
Insurance Agent |
Dubuque |
Dubuque |
Iowa |
Kim Esser |
Michelle Huss |
Signed |
846 |
2022-01-20 12:02 |
Anonymous (not verified) |
97.107.199.129 |
Moval Motors LLC |
Limited Liability Company |
3153 Joliet Ave Missouri Valley IA 51555 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2022-01-19 |
Michael Porter |
msporter8855@hotmail.com |
Papillion |
sarpy |
Nebraska |
Jon Paul Burton |
Scott Porter |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Micahel Porter |
mporter8855@hotmail.com |
secretary of Moval |
Papillion |
Sarpy |
Nebraska |
Jon Paul Bruton |
Scott Porter |
Signed |
126 |
2020-04-21 21:19 |
Anonymous (not verified) |
69.76.135.87 |
Merge Midwest Engineering, LLC |
Limited Liability Company |
2668 W. Catalpa Street |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2020-04-21 |
Mark Daniel Stuempel |
mstuempel@mergemidwest.com |
Kansas City |
Wyandotte |
KANSAS |
Anna Langer |
Donna Stuempel |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Janelle Clayton |
jclayton@mergemidwest.com |
LLC Member |
Olathe |
Johnson |
KS |
Anna Langer |
Donna Stuempel |
Signed |
489 |
2021-04-20 13:47 |
Anonymous (not verified) |
69.63.16.2 |
Mow-n-Mor Lawn & Landscaping LLC |
Limited Liability Company |
2585 500th St SW, Kalona, IA 52247 |
I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation. |
I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer. |
I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer. |
(1) I am not electing the employers’ liability coverage. |
2021-04-19 |
Robert Sieren |
mtesdell@yahoo.com |
Kalona |
Johnson |
Iowa |
Scott Freeman |
Dyan Kriener |
Signed |
(1) The employer does not elect the employers’ liability coverage. |
Robert Sieren |
mtesdell@yahoo.com |
Managing Member |
Kalona |
Johnson |
Iowa |
Scott Freeman |
Dyan Kriener |
Signed |